Nokea
The nurse is caring for the following assigned clients. The nurse should prioritize following up with the client
- A. who had a myocardial infarction two days ago, and has an elevated troponin level.
- B. with infective endocarditis who wants to leave against medical advice (AMA).
- C. who has arterial insufficiency and is reporting leg pain after walking in the hall.
- D. recovering from cardiac catheterization, who has developed atrial fibrillation.
Correct Answer: D
Rationale: Atrial fibrillation post-cardiac catheterization (D) is a new, potentially unstable arrhythmia requiring immediate follow-up. Elevated troponin (A) is expected post-MI, AMA (B) needs discussion, and leg pain (C) is less urgent.
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A charge nurse is preparing client assignments for the shift. Which client is most appropriate to assign to a licensed practical/vocational nurse (LPN/VN)?
- A. A client with a chest tube requiring frequent oral suctioning.
- B. A client receiving continuous IV heparin for a pulmonary embolism (PE).
- C. A client 24 hours post-abdominal surgery requiring daily wound care.
- D. A client with new-onset seizures awaiting diagnostic tests.
Correct Answer: C
Rationale: A client 24 hours post-abdominal surgery needing wound care (C) is stable and within the LPN scope. Chest tube suctioning (A) and heparin infusion (B) require RN monitoring for complications. New-onset seizures (D) require RN assessment due to instability.
The nurse is caring for assigned clients. Which of the following actions would reflect effective care coordination? Select all that apply.
- A. Arranging for an interdisciplinary conference
- B. Consulting with case management for a discharge plan
- C. Initiating appropriate outpatient referrals
- D. Performing post-discharge phone calls
- E. Implementing transmission-based precautions
Correct Answer: A, B, C, D
Rationale: Effective care coordination includes interdisciplinary conferences (A), case management for discharge (B), outpatient referrals (C), and post-discharge follow-up (D). Transmission precautions (E) are infection control, not care coordination.
The nurse enters the room of a 5-year-old client and finds the client lying on the floor. The fall was unwitnessed. What is the priority nursing action?
- A. File an incident report
- B. Assist the child back to bed
- C. Call for help
- D. Assess the child for any injuries
Correct Answer: D
Rationale: Assessing the child for injuries (D) is the priority to identify potential harm, such as head trauma. Calling for help (C), assisting back to bed (B), and filing a report (A) follow after ensuring the child’s safety.
The emergency department (ED) nurse is assigned clients with assigned clients. Place the actions in the order of priority, starting with the highest priority.
- A. Dress a wound for a client discharged with multiple lacerations to the right arm.
- B. Insert a peripheral vascular access device for a client with mild dehydration and infuse prescribed fluids.
- C. Assess a client’s blood pressure who is receiving an infusion of dopamine.
- D. Witness informed consent for a client scheduled for surgery in six hours.
- E. Administer prescribed magnesium sulfate infusion for a client with status asthmaticus.
Correct Answer: C, E, B, D, A
Rationale: Assessing BP on dopamine (C) ensures hemodynamic stability, followed by magnesium for status asthmaticus (E) to control life-threatening bronchospasm. IV access for dehydration (B), informed consent (D), and wound dressing (A) are less urgent, as they address stable or non-emergent needs.
The nurse is caring for a client one day post-operative following a left hip arthroplasty. Which assessment finding requires immediate follow-up?
- A. Restlessness
- B. Blood glucose 155 mg/dL (8.61 mmol/L) [70 to 110 mg/dL]
- C. Temperature 99.7°F (37.6°C)
- D. Pain with movement in the left leg
Correct Answer: A
Rationale: Restlessness post-hip arthroplasty (A) may indicate complications like hypoxia, bleeding, or dislocation, requiring immediate intervention. Glucose elevation (B), mild fever (C), and pain with movement (D) are expected or less urgent.