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The nurse is triaging phone calls in the prenatal clinic. The nurse should initially follow-up on the client who is
- A. 16 weeks of gestation and reports a fluttering sensation.
- B. 30 weeks of gestation and reports perianal itching and bright red blood in the stool.
- C. 28 weeks of gestation and reports intermittent leg cramping with swelling in her feet.
- D. 38 weeks of gestation and reports lower back pain that increases with walking.
Correct Answer: B
Rationale: Bright red blood in the stool at 30 weeks gestation (B) suggests possible hemorrhoids, rectal fissure, or other complications, requiring urgent follow-up to rule out serious conditions. Fluttering at 16 weeks (A) is normal quickening, leg cramps and swelling at 28 weeks (C) are common, and back pain at 38 weeks (D) is typical, all less urgent.
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The nurse from the medical-surgical unit is calling a telephone report to the cardiac intensive care unit nurse regarding a client who is being transferred for a change in condition. Using the identification, situation, background, assessment, and recommendation (ISBAR) format, place the following communication steps in the order in which they should be performed, starting from first to last.
- A. He is a 56-year-old male admitted two days ago with community-acquired pneumonia. He has a medical history of diabetes mellitus and depression.
- B. His most recent vital signs were blood pressure 160/100, pulse 113, respirations 30, temperature 99, and oxygen saturation 89%. He is experiencing significant dyspnea and substernal chest pain radiating to the arm. The 12-lead electrocardiogram showed ST-elevation in two leads. Nasal cannula oxygen was applied, and 2 mg of IV morphine was given.
- C. Mr. Joe Smith is being transferred because he has trouble breathing and reports chest pain not relieved with nitroglycerin.
- D. Dr. Adams ordered a transfer because of confirmed myocardial infarction and to be treated with intravenous thrombolytics. When he arrives at the unit, he has an order for intravenous nitroglycerin infusion.
- E. I am the medical-surgical nurse calling to report about Mr. Joe Smith, the client being transferred with acute coronary syndrome.
Correct Answer: E, C, A, B, D
Rationale: Using ISBAR: 1. Identification (E) introduces the nurse and client. 2. Situation (C) outlines the current issue (chest pain, dyspnea). 3. Background (A) provides history. 4. Assessment (B) details vital signs and findings. 5. Recommendation (D) includes transfer orders and next steps.
Which statement about the placebo is the most accurate?
- A. Placebos are often used to determine if the client's reports of pain are valid.
- B. Placebos are not used in research because the client has not given consent.
- C. Placebo use is unethical unless they are used in research with the subject's consent.
- D. Placebo use is illegal according to all states and the federal government.
Correct Answer: C
Rationale: Placebo use is ethical in research with informed consent (C), as it ensures transparency. Using placebos to validate pain (A) is unethical, placebos are used in research (B), and they are not illegal (D).
The nurse in the emergency department (ED) is caring for a client who intentionally overdosed on their prescribed lithium. The nurse plans on initially
- A. developing a therapeutic rapport with the client.
- B. inserting a peripheral vascular access device.
- C. obtaining the client’s vital signs.
- D. collecting a serum lithium level on the client.
Correct Answer: B
Rationale: Inserting a peripheral vascular access device (B) is the initial priority in a lithium overdose to enable rapid administration of fluids or medications to stabilize the client. Vital signs (C) and lithium levels (D) follow, and rapport (A) is secondary to medical stabilization.
The charge nurse is assigning tasks to an unlicensed assistive personnel (UAP). Which task would be appropriate to delegate to the UAP?
- A. Collecting a urine specimen from an indwelling urinary catheter.
- B. Increase nasal cannula oxygen for a client by one liter a minute.
- C. Record how much drainage is in the suction cannister.
- D. Remove a nitroglycerin patch before giving a bath.
Correct Answer: A
Rationale: Collecting a urine specimen from an indwelling catheter (A) is within the UAP’s scope with proper training. Adjusting oxygen (B), recording drainage (C), and removing a medicated patch (D) involve clinical judgment or medication administration, reserved for nurses.
The risk manager reviews an incident report completed by a nurse regarding a client’s fall. Which finding in the report demonstrates inappropriate documentation?
- A. The client’s explanation of the event.
- B. Subjective factors preceding the fall.
- C. Any injuries sustained as a result of the fall.
- D. The names of all witnesses present.
Correct Answer: B
Rationale: Subjective factors (B) are inappropriate in incident reports, as they may include opinions rather than objective facts. The client’s explanation (A), injuries (C), and witness names (D) are factual and appropriate to document.