Nokea
The nurse is triaging phone calls at the physician’s office. The nurse should initially follow-up on the client who had
- A. cataract lens extraction one day ago and is reporting persistent nausea and vomiting.
- B. laparoscopic hysterectomy two days ago and is reporting pain with urination.
- C. ileostomy placement three days ago and is reporting that the stoma is swollen.
- D. total hip arthroplasty four days ago and refused physical therapy due to increased pain.
Correct Answer: A
Rationale: Persistent nausea and vomiting post-cataract surgery (A) suggest possible complications like increased intraocular pressure, requiring immediate follow-up. Dysuria (B), stoma swelling (C), and therapy refusal (D) are less urgent, as they are common or non-emergent.
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The medical-surgical nurse is assigned to the intensive care unit (ICU). The nurse accepts the hand-off reports and indicates they are not qualified to provide the necessary care. It would be appropriate for the medical-surgical nurse to take which action?
- A. Refuse to provide any client care
- B. Document the concern in the client's medical record
- C. Notify the primary healthcare provider (PHCP)
- D. Report the concerns to the nursing supervisor
Correct Answer: D
Rationale: Reporting concerns to the nursing supervisor (D) ensures safe staffing and reassignment, protecting clients and the nurse. Refusing care (A) is unprofessional, documenting in records (B) is inappropriate, and notifying the provider (C) is not the nurse’s role.
You are the charge nurse on a medical-surgical unit. You have noticed over the last several weeks that one of the nurses on your team is displaying anger and negative feelings, which is not at all characteristic of this experienced nurse. What is this nurse most likely experiencing?
- A. Burnout
- B. Role confusion and dissonance
- C. Ineffective role performance
- D. Fatigue
Correct Answer: A
Rationale: Persistent anger and negative feelings (A) in an experienced nurse suggest burnout, a state of emotional and physical exhaustion from prolonged stress. Role confusion (B), ineffective performance (C), and fatigue (D) may contribute but are less specific to the described emotional changes.
The registered nurse (RN) is working with a licensed practical/vocational nurse (LPN/VN). Which client assignment should the RN delegate to the LPN? A client
- A. immediately post-operative following a thyroidectomy.
- B. with a paralytic ileus requiring the management of a nasogastric tube.
- C. receiving intravenous magnesium sulfate for status asthmaticus.
- D. with a hypertensive crisis requiring initiation of intravenous nicardipine.
Correct Answer: B
Rationale: Managing a nasogastric tube for paralytic ileus (B) is within the LPN’s scope for stable clients. Post-thyroidectomy (A), magnesium sulfate (C), and hypertensive crisis (D) require RN monitoring due to critical risks.
The nurse has been made aware of the following client situations. The nurse should first assess the client
- A. who recently received tissue plasminogen activator (tPA) and has oozing at the insertion site of the peripheral vascular access device.
- B. who has acute kidney injury (AKI) and has voided 100 mL of urine in the past six hours.
- C. who has pericarditis and is sitting upright in the bed, leaning forward to help relieve the chest pain.
- D. has an intractable migraine headache and has vomited twice in the past two hours.
Correct Answer: A
Rationale: Oozing at the tPA insertion site (A) suggests bleeding risk, a critical complication due to thrombolytic therapy, requiring immediate assessment. Oliguria in AKI (B), pericarditis pain relief (C), and migraine with vomiting (D) are less urgent.
Which of the following is the first nursing action for a patient experiencing dyspnea?
- A. Remove pillows from under the patient's head
- B. Elevate the head of the bed
- C. Elevate the foot of the bed
- D. Take the patient's blood pressure
Correct Answer: B
Rationale: Elevating the head of the bed (B) is the first action for dyspnea to improve lung expansion and ease breathing. Removing pillows (A) may worsen discomfort, elevating the foot (C) is irrelevant, and taking blood pressure (D) is secondary.