Nokea
The nurse is reviewing the plan of care for a client admitted to the behavioral health unit with anorexia nervosa. The nurse understands that the priority goal for this client is
- A. attending scheduled group therapy.
- B. adhere to the medication regimen.
- C. gain one pound (half a kilogram) a week.
- D. demonstrate increased self-esteem.
Correct Answer: C
Rationale: Gaining one pound (half a kilogram) per week (C) is the priority goal for anorexia nervosa to address life-threatening malnutrition and stabilize physical health. Attending group therapy (A), adhering to medications (B), and improving self-esteem (D) are important but secondary to restoring nutritional status to prevent organ failure.
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The nurse is triaging a client involved in a chemical spill at a local chemical plant. The nurse assesses the client as responsive but unable to walk, with a respiratory rate of 28 and capillary refill <2 seconds. It would be correct for the nurse to triage this client with a
- A. yellow tag.
- B. red tag.
- C. black tag.
- D. green tag.
Correct Answer: A
Rationale: A yellow tag (A) is appropriate for a responsive client unable to walk with stable vital signs (RR 28, capillary refill <2 sec), indicating urgent but not immediate life-threatening needs. Red (B) is for critical, black (C) for deceased, and green (D) for minor injuries.
The nurse in charge of the labor and delivery department is making the client assignments for the day. Which client should the most experienced nurse receive?
- A. A 40-week pregnant client attached to the fetal monitor having late decelerations.
- B. A 39-week pregnant client in labor with contractions 3 minutes apart.
- C. A 33-week pregnant client with triplets who is on bed rest.
- D. A 26-week pregnant client who is having Braxton Hicks contractions.
Correct Answer: A
Rationale: Late decelerations at 40 weeks (A) indicate fetal distress, requiring the most experienced nurse for close monitoring and potential intervention. Active labor (B), preterm triplets (C), and Braxton Hicks (D) are less critical or stable, suitable for less experienced staff.
The charge nurse is assigning tasks to an unlicensed assistive personnel (UAP). Which task would be appropriate to delegate to the UAP?
- A. Collecting a urine specimen from an indwelling urinary catheter.
- B. Increase nasal cannula oxygen for a client by one liter a minute.
- C. Record how much drainage is in the suction cannister.
- D. Remove a nitroglycerin patch before giving a bath.
Correct Answer: A
Rationale: Collecting a urine specimen from an indwelling catheter (A) is within the UAP’s scope with proper training. Adjusting oxygen (B), recording drainage (C), and removing a medicated patch (D) involve clinical judgment or medication administration, reserved for nurses.
The nurse from the medical-surgical unit is calling a telephone report to the cardiac intensive care unit nurse regarding a client who is being transferred for a change in condition. Using the identification, situation, background, assessment, and recommendation (ISBAR) format, place the following communication steps in the order in which they should be performed, starting from first to last.
- A. He is a 56-year-old male admitted two days ago with community-acquired pneumonia. He has a medical history of diabetes mellitus and depression.
- B. His most recent vital signs were blood pressure 160/100, pulse 113, respirations 30, temperature 99, and oxygen saturation 89%. He is experiencing significant dyspnea and substernal chest pain radiating to the arm. The 12-lead electrocardiogram showed ST-elevation in two leads. Nasal cannula oxygen was applied, and 2 mg of IV morphine was given.
- C. Mr. Joe Smith is being transferred because he has trouble breathing and reports chest pain not relieved with nitroglycerin.
- D. Dr. Adams ordered a transfer because of confirmed myocardial infarction and to be treated with intravenous thrombolytics. When he arrives at the unit, he has an order for intravenous nitroglycerin infusion.
- E. I am the medical-surgical nurse calling to report about Mr. Joe Smith, the client being transferred with acute coronary syndrome.
Correct Answer: E, C, A, B, D
Rationale: Using ISBAR: 1. Identification (E) introduces the nurse and client. 2. Situation (C) outlines the current issue (chest pain, dyspnea). 3. Background (A) provides history. 4. Assessment (B) details vital signs and findings. 5. Recommendation (D) includes transfer orders and next steps.
The emergency department (ED) nurse cares for a client who presents with irritability, nuchal rigidity, and a fever. Which of the following actions should the nurse take first?
- A. Administer prescribed ibuprofen.
- B. Place the client on droplet precautions.
- C. Notify the public health department.
- D. Obtain prescribed blood cultures.
Correct Answer: B
Rationale: Placing the client on droplet precautions (B) is the first action for suspected meningitis (irritability, nuchal rigidity, fever) to prevent spread of infection. Administering ibuprofen (A), notifying public health (C), and obtaining blood cultures (D) are important but secondary to infection control.