Nokea
The nurse is triaging phone calls for the primary healthcare provider (PHCP). Which client situation requires immediate notification to the PHCP?
- A. A client with heart failure that reports an overnight weight gain of three pounds.
- B. A client with peritoneal dialysis who has not had a bowel movement in two days.
- C. A client with irritable bowel syndrome (IBS) that reports frequent diarrhea.
- D. A client with nephrolithiasis that reports bloody urine and flank pain.
Correct Answer: A
Rationale: Rapid weight gain of three pounds overnight in heart failure (A) indicates fluid overload, a potential precursor to acute decompensation, requiring immediate PHCP notification. Constipation in peritoneal dialysis (B), frequent diarrhea in IBS (C), and hematuria with flank pain in nephrolithiasis (D) are concerning but less immediately life-threatening.
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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.
The nurse administers intravenous levofloxacin instead of the prescribed azithromycin. Which of the following actions should the nurse take first?
- A. Stop the infusion
- B. Complete an incident report
- C. Obtain vital signs
- D. Notify the primary healthcare provider (PHCP)
Correct Answer: A
Rationale: Stopping the infusion (A) is the first action to prevent further harm from the medication error. Notifying the provider (D), obtaining vital signs (C), and completing an incident report (B) follow after halting the incorrect medication.
The nurse is caring for a client who is six hours post-operative from a laparoscopic appendectomy. Which of the following findings requires immediate follow-up?
- A. Incisional pain rated 6 on a scale of 0 (no pain) to 10 (severe pain)
- B. Oral temperature of 99.5°F (37.5°C)
- C. Heart rate of 112 beats-per-minute (BPM)
- D. Hypoactive bowel sounds in all four quadrants
Correct Answer: C
Rationale: Tachycardia (112 BPM) at six hours post-operative (C) suggests possible complications like bleeding or infection, requiring immediate follow-up. Pain rated 6 (A) is expected, mild fever (B) is normal, and hypoactive bowel sounds (D) are typical post-surgery.
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.
The nurse is caring for the following assigned clients. It would be a priority to follow up with a client who
- A. has atrial fibrillation and a heart rate of 112/minute.
- B. has glomerulonephritis with a blood pressure of 137/86 mm Hg.
- C. is receiving amphotericin B, and the most recent temperature is 100.4°F (38°C).
- D. has chronic obstructive pulmonary disease (COPD) with an oxygen saturation of 91% on room air.
Correct Answer: A
Rationale: Atrial fibrillation with a heart rate of 112/minute (A) indicates a rapid ventricular response, risking hemodynamic instability or stroke, requiring immediate rate control. Glomerulonephritis with normal BP (B), mild fever with amphotericin (C), and COPD with 91% saturation (D) are less urgent, as they are stable or expected.