Nokea
The nurse is triaging clients in the emergency department (ED). Which client should the nurse triage as emergent? A client
- A. reporting pleuritic chest pain with a productive cough.
- B. who is pregnant and reporting intermittent nausea and vomiting.
- C. who has an isolated area of reddened vesicles and malaise.
- D. with sudden onset of ataxia and dysarthria.
Correct Answer: D
Rationale: Sudden ataxia and dysarthria (D) suggest a stroke, an emergent condition requiring immediate triage for time-sensitive intervention. Pleuritic cough (A), pregnancy nausea (B), and vesicles/malaise (C) are less urgent.
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The nurse is caring for a client with a platelet count of 18,000 mm3 [150,000-400,000 mm3]. What is the priority action the nurse should take?
- A. Review the client's most recent liver function tests.
- B. Educate the client to notify staff before getting out of bed.
- C. Obtain and monitor the client's temperature.
- D. Encourage the client to turn, cough, and deep breathe.
Correct Answer: B
Rationale: Severe thrombocytopenia (18,000 mm3) (B) risks bleeding, so educating the client to notify staff before moving prevents injury. Liver tests (A), temperature (C), and respiratory exercises (D) are secondary to immediate safety measures.
The nurse is providing care for a patient recently transferred from the post-anesthesia care unit [PACU]. The chart indicates that the patient was medicated for pain 1 hour ago, yet the patient reports that he is experiencing extreme pain. He is not due for further medication until another 2 hours. How might the nurse intervene as a patient advocate?
- A. Contact the physician regarding the need for more effective pain management.
- B. Assist the patient to use non-pharmacological pain management strategies.
- C. Explain to the patient that giving the pain medication too soon can be dangerous.
- D. Provide a quiet environment to help the patient rest and cope with his pain level.
Correct Answer: A
Rationale: Contacting the physician (A) advocates for the patient by addressing uncontrolled pain, potentially adjusting the regimen. Non-pharmacological strategies (B), explaining risks (C), or providing a quiet environment (D) are supportive but do not directly address the need for better pain control.
The nurse plans care for a client with a vancomycin-resistant enterococcus (VRE) infection. Which action should the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. Place gowns and gloves outside of the client’s room
- B. Educate the client and family members on ways to prevent transmission of VRE
- C. Affix a droplet precautions sign on the client’s door
- D. Validate the client’s understanding on hand hygiene
Correct Answer: A
Rationale: Placing gowns and gloves outside the room (A) is a non-clinical task within the UAP’s scope. Education (B), signage for droplet precautions (C, incorrect for VRE), and validating understanding (D) require clinical judgment and are RN/LPN responsibilities.
When experiencing conflict with another nurse (that is not resolvable between the parties), what is the most appropriate action for the nurse moving forward?
- A. Report the conflict to the director of nursing over the unit.
- B. Report the conflict to the nurse manager of the unit.
- C. Report the conflict to the assigned charge nurse of the unit.
- D. Discuss the conflict with another nurse to attempt resolution of the issue.
Correct Answer: B
Rationale: Reporting to the nurse manager (B) follows the chain of command for unresolved conflict, ensuring appropriate resolution. The director (A) is too high, the charge nurse (C) may lack authority, and discussing with another nurse (D) risks gossip and unprofessionalism.
The nurse is planning to interview a client interested in establishing care with a primary healthcare provider (PHCP). The nurse should initially
- A. obtain the client's vital signs.
- B. identify the client's chief complaint.
- C. provide a private area for the interview.
- D. inquire about the client's allergies.
Correct Answer: C
Rationale: Providing a private area (C) ensures confidentiality and comfort, the initial step for an interview. Chief complaint (B), allergies (D), and vital signs (A) follow after establishing privacy.