Nokea
The nurse is triaging a group of pediatric clients. The nurse should first see the client who is
- A. reporting pain 5/10 on the Numerical Rating Scale after burning their right forearm.
- B. drooling and experiencing difficulty with swallowing.
- C. experiencing a temperature of 101.1°F (38.4°C) and a headache.
- D. reporting excessive thirst and has a thready peripheral pulse.
Correct Answer: B
Rationale: Drooling and difficulty swallowing (B) suggest airway obstruction, such as epiglottitis, a life-threatening emergency. Burns (A), fever with headache (C), and thirst with thready pulse (D) are concerning but less immediately critical.
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The nurse and unlicensed assistive personnel (UAP) are caring for assigned clients. Which of the following tasks would be appropriate for the nurse to assign to UAP?
- A. Providing oral care for an unconscious client with a tracheostomy
- B. Assisting a client with diabetes in monitoring blood glucose levels
- C. Assisting a client with a history of falls with ambulation in the hallway
- D. Assisting a client with wound dressing changes for a surgical incision
Correct Answer: C
Rationale: Assisting with ambulation for a client with fall risk (C) is within the UAP’s scope, ensuring safety with supervision. Oral care for tracheostomy (A), glucose monitoring (B), and dressing changes (D) require clinical judgment or sterility, inappropriate for UAPs.
The nurse is caring for assigned clients. Which of the following clients would be appropriate for the nurse to refer for an interdisciplinary conference? A client with Select all that apply.
- A. pulmonary tuberculosis with multiple prescriptions.
- B. ischemic stroke who has left-sided hemiplegia.
- C. hyperthyroidism and is scheduled for a thyroidectomy.
- D. stage one Alzheimer’s disease who lives with family.
- E. fractured tibia and fibula and is homeless.
- F. end-stage-renal disease who refuses dialysis.
Correct Answer: A, B, E, F
Rationale: TB with multiple drugs (A), stroke with hemiplegia (B), homeless with fractures (E), and dialysis refusal (F) require interdisciplinary coordination due to complex medical, social, or ethical needs. Thyroidectomy (C) and early Alzheimer’s (D) are less complex for conferencing.
The nurse manager has observed a staff nurse return to work late multiple times following the lunch break. The nurse manager should take which initial action?
- A. Continue to observe the nurse's behavior
- B. Reprimand the nurse with written documentation
- C. Ask the nurse to check in before and after taking their lunch break
- D. Discuss with the nurse the consequences of being late
Correct Answer: C
Rationale: Asking the nurse to check in (C) is a proactive initial step to address tardiness while maintaining professionalism and gathering data. Continued observation (A) delays action, reprimand (B) is premature, and discussing consequences (D) escalates without initial intervention.
The emergency department (ED) nurse is caring for a client who is 38 weeks pregnant and experiencing frequent contractions. The nurse observes a presenting part of the fetus during the exam. Which priority action should the nurse take?
- A. Assess the client's previous obstetric history
- B. Prepare for the delivery of the newborn
- C. Transport the client to the labor and delivery unit
- D. Time the frequency and duration of contractions
Correct Answer: B
Rationale: A visible presenting part (B) indicates imminent delivery, requiring immediate preparation for newborn delivery in the ED. Assessing history (A), transporting to labor and delivery (C), or timing contractions (D) delays critical action for an emergency birth.
The nurse is caring for a client with a percutaneous endoscopic gastrostomy tube. Prior to administering the next tube feeding, the nurse aspirates 80 mL of gastric residual. The nurse should then
- A. notify the physician.
- B. hold the tube feeding and recheck residual volume in one hour.
- C. administer the prescribed feeding.
- D. reposition the patient in low-Fowler's position.
Correct Answer: B
Rationale: An 80 mL gastric residual (B) indicates potential delayed gastric emptying, requiring the nurse to hold the feeding and recheck in one hour to prevent aspiration. Notifying the physician (A) is premature, administering feeding (C) risks complications, and low-Fowler’s (D) is inappropriate for feeding.