Nokea
The nurse is triaging phone calls at a clinic. The nurse should initially follow-up with the client who reports
- A. decreased libido while receiving prescribed dutasteride.
- B. swelling in their right leg while receiving prescribed tamoxifen.
- C. hot flashes and night sweats while receiving prescribed letrozole.
- D. bone pain while receiving prescribed filgrastim.
Correct Answer: B
Rationale: Right leg swelling on tamoxifen (B) suggests deep vein thrombosis, a life-threatening emergency requiring immediate follow-up. Decreased libido (A), hot flashes (C), and bone pain (D) are expected side effects and less urgent.
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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.
A nurse is working in a busy medical-surgical unit and has received report on the following four clients. The nurse should first see the client with
- A. A client who underwent surgery yesterday and is complaining of incisional pain at a level of 8/10
- B. new-onset atrial fibrillation who is complaining of chest pain.
- C. diabetes who has a foot wound that appears infected and an oral temperature of 100.4°F (38°C)
- D. advanced Alzheimer's disease who is confused and has had a recent fall.
Correct Answer: B
Rationale: New-onset atrial fibrillation with chest pain (B) suggests possible cardiac ischemia, a life-threatening emergency requiring immediate assessment. Severe pain (A), infected foot wound (C), and confusion post-fall (D) are urgent but less immediately life-threatening.
The charge nurse is supervising unlicensed assistive personnel (UAPs). The charge nurse should immediately intervene when a UAP is observed
- A. assisting a client with multiple sclerosis to shower.
- B. applying a condom catheter to a client who is incontinent.
- C. transporting a client with myocardial infarction to the cardiac catheterization lab.
- D. obtaining vital signs for a client with delirium.
Correct Answer: C
Rationale: Transporting a client with myocardial infarction (C) by a UAP is unsafe, as they require continuous monitoring for cardiac instability. Shower assistance (A), condom catheter application (B), and vital signs (D) are within UAP scope.
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.
During a busy shift, the nurse appropriately delegates tasks to the unlicensed assistive personnel (UAP). Which of the following is the nurse's primary responsibility?
- A. Document the completion of the task.
- B. Make a list of tasks not yet completed to pass on to the next shift.
- C. Observe the UAP for the duration of the task.
- D. Follow-up with the UAP to ensure completion of the task and evaluate the outcome.
Correct Answer: D
Rationale: The nurse’s primary responsibility is to follow up with the UAP (D) to ensure tasks are completed correctly and evaluate outcomes, maintaining accountability for delegated care. Documentation (A), listing incomplete tasks (B), and continuous observation (C) are not primary responsibilities.