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The nurse is performing an assessment on a client with pneumonia. The nurse should prioritize assessing the client's
- A. temperature.
- B. oral intake.
- C. lung sounds.
- D. white blood cell count.
Correct Answer: C
Rationale: Lung sounds (C) are the priority in pneumonia to assess for consolidation or respiratory compromise, guiding immediate interventions. Temperature (A), intake (B), and WBC count (D) are important but secondary, as they inform longer-term management.
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The nurse is triaging phone calls at the mental health clinic. Which client situation requires immediate follow-up? A client prescribed
- A. olanzapine reporting muscle stiffness and feeling hot.
- B. haloperidol reporting blurred vision and constipation.
- C. clozapine reporting occasional twitches of the mouth.
- D. aripiprazole reporting feeling very restless.
Correct Answer: A
Rationale: Muscle stiffness and feeling hot with olanzapine (A) suggest neuroleptic malignant syndrome, a life-threatening emergency requiring immediate follow-up. Blurred vision/constipation (B), mouth twitches (C), and restlessness (D) are less urgent side effects.
The charge nurse is making assignments in the intensive care unit (ICU) and is making client assignments for a nurse floated from the medical-surgical (med-surg) unit. Which client would be appropriate to assign to the nurse floated from med-surg?
- A. A client with bacteremia who is suspected of developing shock.
- B. A client requiring the titration of intravenous (IV) vasopressors based on hemodynamic monitoring.
- C. A client receiving intravenous (IV) antibiotics and nebulizer treatments for pneumonia.
- D. A client with targeted temperature management three hours after experiencing cardiac arrest.
Correct Answer: C
Rationale: A client receiving IV antibiotics and nebulizers for pneumonia (C) is stable and aligns with med-surg skills, suitable for a float nurse. Bacteremia with shock (A), vasopressor titration (B), and targeted hypothermia (D) require ICU expertise.
The nurse is caring for a client who fell off the ladder. The client reports numbness in his lower extremities. The nurse should initially
- A. assess the client for lacerations
- B. evaluate the range of motion of the client's neck
- C. provide cervical spine stabilization
- D. assess the client's range of motion in the lower extremities
Correct Answer: C
Rationale: Numbness in lower extremities suggests spinal cord injury, requiring immediate cervical spine stabilization (C) to prevent further damage. Assessing lacerations (A), neck range of motion (B), or lower extremity motion (D) risks exacerbating injury.
The charge nurse reviews medical records for clients ready for discharge from the nursing unit. Which client should be recommended for disease management services? A client with
- A. congestive heart failure (CHF), who has been admitted three times in the past two months.
- B. epilepsy who had one seizure after switching prescribed antiepileptics.
- C. diabetes mellitus, with an increase in hemoglobin A1C from 6.7% to 6.9%.
- D. schizophrenia being switched from daily dosing to long-acting injectable antipsychotic.
Correct Answer: A
Rationale: Frequent CHF admissions (A) indicate poor disease control, making the client ideal for disease management services to prevent readmissions. Seizure after medication change (B), slight A1C increase (C), and schizophrenia medication switch (D) are less indicative of ongoing management needs.
While caring for a client who requires a mechanical ventilator for breathing, the high-pressure alarm goes off on the ventilator. What is the first action the nurse should perform?
- A. Disconnect the client from the ventilator and use a manual resuscitation bag.
- B. Perform a quick assessment of the client's condition.
- C. Call the respiratory therapist for help.
- D. Press the alarm reset button on the ventilator.
Correct Answer: B
Rationale: A high-pressure alarm suggests obstruction or resistance, so assessing the client’s condition (B) first identifies the cause (e.g., tube kinking, secretions). Disconnecting (A), calling for help (C), or resetting (D) without assessment risks harm or delays resolution.