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The nurse is providing patient care working in a unit that uses the total patient care model for delivering nursing care. The nurse recognizes which of the following as an aspect of this nursing care delivery model?
- A. The RN assumes responsibility for a caseload of patients.
- B. The RN supervises team members providing direct patient care.
- C. The RN provides care for the same patients during their hospital stay.
- D. The RN is responsible for all aspects of care during a shift of care.
Correct Answer: D
Rationale: In the total patient care model, the RN is responsible for all aspects of care for assigned clients during a shift (D). Caseload responsibility (A) and continuity of care (C) are partial aspects, and supervision (B) aligns more with team nursing, not total patient care.
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The nurse is caring for the following assigned clients. It would be a priority to follow up with a client who
- A. has atrial fibrillation and a heart rate of 112/minute.
- B. has glomerulonephritis with a blood pressure of 137/86 mm Hg.
- C. is receiving amphotericin B, and the most recent temperature is 100.4°F (38°C).
- D. has chronic obstructive pulmonary disease (COPD) with an oxygen saturation of 91% on room air.
Correct Answer: A
Rationale: Atrial fibrillation with a heart rate of 112/minute (A) indicates a rapid ventricular response, risking hemodynamic instability or stroke, requiring immediate rate control. Glomerulonephritis with normal BP (B), mild fever with amphotericin (C), and COPD with 91% saturation (D) are less urgent, as they are stable or expected.
The nurse is conducting a staff education program about hand-off reports for clients in an acute care environment. Which of the following should be included during the hand-off report? Select all that apply.
- A. emergency code status
- B. allergies
- C. home medications
- D. admitting diagnosis
- E. review of previous hospitalizations
- F. health insurance status
Correct Answer: A, B, C, D
Rationale: Code status (A), allergies (B), home medications (C), and admitting diagnosis (D) are critical for safe care transitions per ISBAR standards. Previous hospitalizations (E) and insurance status (F) are not essential for immediate handoff.
The nurse has completed medication administration to assigned clients. The nurse should initially follow up on the client who received prescribed
- A. mirtazapine and reports sleepiness.
- B. citalopram and reports nausea.
- C. fluphenazine and reports fever.
- D. clonidine and reports dizziness while rolling over in bed.
Correct Answer: C
Rationale: Fever after fluphenazine (C) suggests neuroleptic malignant syndrome, a life-threatening emergency requiring immediate follow-up. Sleepiness with mirtazapine (A), nausea with citalopram (B), and dizziness with clonidine (D) are expected side effects and less urgent.
The nurse is caring for assigned clients. After administering prescribed medications, the nurse should immediately intervene if the client reports
- A. nausea during an infusion of amphotericin B.
- B. palpitations after receiving rapid-acting insulin.
- C. drowsiness after receiving fentanyl.
- D. itching in the perineal area while receiving intravenous dexamethasone.
Correct Answer: B
Rationale: Palpitations after rapid-acting insulin (B) suggest hypoglycemia or an adverse reaction, requiring immediate intervention to assess and stabilize. Nausea with amphotericin B (A), drowsiness with fentanyl (C), and itching with dexamethasone (D) are expected side effects and less urgent.
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.