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The nurse is planning care for a client being admitted with cardiac dysrhythmias. When planning care for this client, the nurse should prioritize
- A. auscultating heart tones.
- B. establishing continuous electrocardiogram (ECG) monitoring.
- C. obtaining vital signs.
- D. establishing a secondary peripheral vascular access device.
Correct Answer: B
Rationale: Continuous ECG monitoring (B) is the priority for cardiac dysrhythmias to detect and manage life-threatening arrhythmias in real-time. Auscultating heart tones (A), vital signs (C), and IV access (D) are important but secondary to monitoring.
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The nurse working on a medical-surgical unit is caring for assigned clients. The nurse should plan to initially assess the client who
- A. had a subtotal thyroidectomy 12 hours ago and reports difficulty swallowing.
- B. reports increased pain following a sterile dressing change for a stage IV pressure ulcer.
- C. has bilateral lower lobe pneumonia and has not used the incentive spirometer in six hours.
- D. is scheduled for an adrenalectomy in eight hours and has not signed the informed consent.
Correct Answer: A
Rationale: Difficulty swallowing post-thyroidectomy (A suggests complications like hematoma or nerve injury, which can be life-threatening and require immediate assessment. Increased pain (B), and not using an incentive spirometer (C), and lack of consent (D) are less urgent and critical.
The nurse manager receives a complaint from a client's family member. The nurse manager should take which initial action?
- A. Tell the night charge nurse to ensure the night shift nurse performs the assigned duties appropriately
- B. Speak with the night shift nurse regarding the complaint and discuss the care provided
- C. Assess the complaint and clarify the details with the family member and client
- D. Take note of the complaint and place it in the applicable employee's file
Correct Answer: C
Rationale: Assessing the complaint and clarifying details with the family and client (C) is the initial step to understand the issue and ensure accurate resolution. Directing the charge nurse (A), speaking with the nurse (B), or filing the complaint (D) are premature without first gathering facts.
The nurse preceptor is observing a newly hired nurse care for assigned clients. It would require follow-up by the nurse preceptor if the newly hired nurse is observed doing which of the following?
- A. Humidifies nasal cannula oxygen for a client with sarcoidosis.
- B. Secures a suprapubic catheter tubing to a client’s inner thigh.
- C. Places a client with varicella-zoster in airborne and contact isolation.
- D. Suctions a tracheostomy for 10 seconds as they remove the catheter.
Correct Answer: D
Rationale: Suctioning a tracheostomy for 10 seconds (D) risks hypoxia and trauma, requiring follow-up as it should be brief (5-10 seconds max). Humidifying oxygen (A), securing catheters (B), and isolating varicella (C) are correct practices.
The nurse is discussing information about advanced directives with a client who expresses concerns, asking, 'What if I change my mind about what I want?' What approach would you use to respond to the client's care?
- A. Explain that the client would have to file a new witnessed document in order to make any changes.
- B. Discuss the need to be very sure about his preferences, as the living will is a binding legal document.
- C. Assure the client that he can change or revoke his advanced directives at any time.
- D. Advise the client that changes could not be made during this hospital stay.
Correct Answer: C
Rationale: Clients can change or revoke advance directives at any time (C), ensuring autonomy. New documents (A) may be needed but not restrictive, living wills are not unchangeable (B), and hospital stay (D) does not limit changes.
The nurse reviews the client's emergency department (ED) triage note. Which action should the nurse take first? See the image below.
- A. Establish continuous cardiac monitoring
- B. Obtain an order for a complete metabolic panel
- C. Obtain a prescription for acetaminophen (APAP)
- D. Apply a cool compress to the client's forehead
Correct Answer: A
Rationale: This client is showing manifestations of digitalis toxicity. The client's bradycardia, anorexia, and vomiting are classic signs of this potentially fatal toxicity. The nurse should immediately establish continuous cardiac monitoring because, if untreated, digitalis toxicity may cause multifocal premature ventricular contractions (PVCs) that may transition to ventricular tachycardia or ventricular fibrillation. Because of digitalis' ability to have a negative chronotropic effect, bradycardia is often seen in toxicity.