Nokea
The nurse is caring for the following assigned clients. The nurse should initially follow-up with the client who
- A. thirty minutes overdue to be ambulated in the hallway.
- B. refusing to eat their meal following an injection of glargine insulin.
- C. scheduled for discharge in three hours and needs transportation.
- D. requesting diphenhydramine after starting an intravenous antibiotic.
Correct Answer: B
Rationale: Refusing to eat after glargine insulin (B) risks hypoglycemia, requiring immediate follow-up to ensure glucose stability. Overdue ambulation (A), discharge planning (C), and diphenhydramine request (D) are less urgent than preventing a metabolic emergency.
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The nurse is caring for an infant who is experiencing a tetralogy of Fallot (tet) spell. The nurse should take which priority action?
- A. Obtain a prescription for propranolol
- B. Establish a peripheral vascular access device
- C. Calm the infant
- D. Notify the healthcare provider
Correct Answer: C
Rationale: Calming the infant (C) during a Tetralogy of Fallot spell reduces oxygen demand and improves oxygenation, the priority action to stop the hypercyanotic episode. Propranolol (A), vascular access (B), and provider notification (D) are secondary to immediate symptom management.
During a busy shift, the nurse appropriately delegates tasks to the unlicensed assistive personnel (UAP). Which of the following is the nurse's primary responsibility?
- A. Document the completion of the task.
- B. Make a list of tasks not yet completed to pass on to the next shift.
- C. Observe the UAP for the duration of the task.
- D. Follow-up with the UAP to ensure completion of the task and evaluate the outcome.
Correct Answer: D
Rationale: The nurse’s primary responsibility is to follow up with the UAP (D) to ensure tasks are completed correctly and evaluate outcomes, maintaining accountability for delegated care. Documentation (A), listing incomplete tasks (B), and continuous observation (C) are not primary responsibilities.
A client has refused a prescribed injection of subcutaneous heparin. Which initial action should the nurse take?
- A. Document the refusal
- B. Notify the primary healthcare provider (PHCP)
- C. Review the client's most recent platelet count
- D. Inquire with the client about the refusal
Correct Answer: D
Rationale: Inquiring about the refusal (D) allows the nurse to understand the client’s concerns, provide education, and address barriers, promoting informed decision-making. Documenting (A) and notifying the provider (B) are secondary steps, and reviewing platelet count (C) is irrelevant without addressing the refusal first.
The medical-surgical nurse is assigned to the intensive care unit (ICU). The nurse accepts the hand-off reports and indicates they are not qualified to provide the necessary care. It would be appropriate for the medical-surgical nurse to take which action?
- A. Refuse to provide any client care
- B. Document the concern in the client's medical record
- C. Notify the primary healthcare provider (PHCP)
- D. Report the concerns to the nursing supervisor
Correct Answer: D
Rationale: Reporting concerns to the nursing supervisor (D) ensures safe staffing and reassignment, protecting clients and the nurse. Refusing care (A) is unprofessional, documenting in records (B) is inappropriate, and notifying the provider (C) is not the nurse’s role.
The nurse has been tasked with developing and leading a multidisciplinary team to improve client safety and has been informed that previous group formations were unsuccessful due to poor team dynamics. When developing and leading this committee, it is essential that the nurse initially
- A. develop a code of conduct for the team.
- B. review how the team will be evaluated.
- C. review the goals for the team.
- D. establish deadlines for the team.
Correct Answer: C
Rationale: Reviewing team goals (C) initially aligns members toward a common purpose, addressing poor dynamics by fostering collaboration. A code of conduct (A), evaluation methods (B), and deadlines (D) are important but secondary to establishing shared objectives.