Nokea
The nurse is triaging phone calls at a clinic for a group of clients. Which client situation requires immediate notification to the primary healthcare provider (PHCP)? A client who
- A. reports a strong metallic-like taste while taking newly prescribed metronidazole.
- B. reports a localized rash after starting prescribed sulfamethoxazole-trimethoprim.
- C. takes prescribed lithium and reports blurred vision.
- D. feels restless and reports difficulty sleeping while taking prescribed prednisone.
Correct Answer: C
Rationale: Blurred vision in a client taking lithium (C) suggests potential lithium toxicity, a medical emergency requiring immediate provider notification. Metallic taste with metronidazole (A) is a common side effect, rash with sulfamethoxazole-trimethoprim (B) needs monitoring but is less urgent, and restlessness with prednisone (D) is a known side effect.
You may also like to solve these questions
The charge nurse is planning patient care assignments for a registered nurse (RN) and licensed practical/vocational nurse (LPN/VN). Which of the following patients would be most appropriate to assign to the LPN?
- A. admitted with acute compartment syndrome awaiting emergency surgery.
- B. with cystic fibrosis who needs an early morning sputum sample collection.
- C. with acute respiratory failure receiving high-flow oxygen therapy.
- D. sepsis requiring multiple intravenous (IV) antibiotics and initiation of vasopressors.
Correct Answer: B
Rationale: Collecting a sputum sample for cystic fibrosis (B) is a stable, routine task within the LPN’s scope. Compartment syndrome (A), respiratory failure (C), and sepsis with vasopressors (D) require RN assessment and management due to their critical nature.
The nurse in the emergency department is caring for a client who sustained multiple rib fractures and a nasal fracture from a motor vehicle crash. Which assessment finding requires immediate follow-up?
- A. shallow respirations
- B. chest pain with repositioning
- C. bruising on the chest
- D. vomiting
Correct Answer: A
Rationale: Shallow respirations (A) in a client with rib fractures suggest impaired ventilation, risking hypoxia or pneumothorax, requiring immediate follow-up. Chest pain (B), bruising (C), and vomiting (D) are expected but less urgent.
The nurse is planning a staff development conference about changing the process of how clients are seen at a clinic to a first come, first served basis. This proposed change will model which ethical principle?
- A. Nonmaleficence
- B. Veracity
- C. Paternalism
- D. Justice
Correct Answer: D
Rationale: A first-come, first-served process (D) models justice by ensuring fair and equitable access to care based on arrival time. Nonmaleficence (A), veracity (B), and paternalism (C) do not apply to this resource allocation change.
The nurse is caring for a group of assigned clients. The nurse should immediately follow up on the client who
- A. has a closed-chest drainage system and has redness at the insertion site.
- B. is receiving treatment for ulcerative colitis and has had three bloody stools in the past hour.
- C. is being treated for a concussion and reports a headache rated as 4 on a scale of 0 (no pain) to 10 (severe pain).
- D. is being treated for an ischemic stroke and has a blood pressure of 100/58 mm Hg.
Correct Answer: D
Rationale: Hypotension (100/58 mm Hg) in ischemic stroke (D) suggests hemodynamic instability, risking cerebral perfusion and requiring immediate follow-up. Redness at chest tube site (A), bloody stools in ulcerative colitis (B), and mild headache in concussion (C) are concerning but less immediately life-threatening.
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? Select all that apply.
- A. Transport a client with an ankle fracture to radiology.
- B. Calculate and record a client's oral intake for the shift.
- C. Ambulate a client who is eight hours post-laparoscopic surgery.
- D. Assist a client with multiple sclerosis in performing oral care.
- E. Obtain a urine culture and sensitivity sample from an indwelling urethral catheter.
Correct Answer: A, C, D
Rationale: UAPs can transport stable clients (A), ambulate post-surgical clients (C), and assist with oral care (D). Calculating intake (B) requires clinical judgment, and obtaining a urine culture (E) involves sterile technique, both RN/LPN tasks.