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The nurse observes a colleague sharing computer credentials with a colleague who is struggling with access to the electronic health record (EHR). Which action should the nurse take?
- A. Warn the colleague that their actions are unprofessional.
- B. Discuss the action at the next staff meeting.
- C. Communicate the observation to the charge nurse.
- D. File a detailed incident report with the specific facility.
Correct Answer: C
Rationale: Reporting to the charge nurse ensures prompt action.
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A client is admitted with pneumonia and has a recent history of methicillin-resistant Staphylococcus aureus (MRSA). The client is placed in isolation. While caring for the client, which item should the nurse place in a designated biohazard bag before it is removed from the room?
- A. Paper mask and gown.
- B. A sputum specimen.
- C. The nurse's stethoscope.
- D. Bed linens.
Correct Answer: A
Rationale: Contaminated mask and gown require biohazard disposal.
A small, round raised area appears under the client's skin as the nurse administers an intradermal medication. Which action should the nurse take?
- A. Elevate the area and apply light pressure over the site.
- B. Apply a cold pack to the area for twenty minutes.
- C. Document the site where the medication was given.
- D. Notify the healthcare provider of the allergic response.
Correct Answer: C
Rationale: Documenting confirms normal intradermal reaction.
The healthcare provider prescribes two doses of an antihypertensive medication for a client. Before administering the second dose, the nurse obtains a blood pressure measurement of 80/50 mm Hg. Which action should the nurse take?
- A. Position the client in a lateral lying position.
- B. Document the blood pressure and monitor the client.
- C. Encourage an increase in oral fluid intake.
- D. Hold the medication and notify the healthcare provider.
Correct Answer: D
Rationale: Holding medication prevents worsening hypotension.
While suctioning a client's nasopharynx, the nurse observes that the client's oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. Which action should the nurse take in response to this finding?
- A. Stop suctioning until the pulse oximeter reading is above 95%.
- B. Reposition the pulse oximeter clip to obtain a new reading.
- C. Complete the intermittent suction of the nasopharynx.
- D. Apply an oxygen mask over the client's nose and mouth.
Correct Answer: B
Rationale: Repositioning ensures accurate saturation readings.
During the prodromal stage of an infection, which is the priority nursing intervention?
- A. Develop a plan for gradually increasing activity and mobility.
- B. Begin discharge planning and teaching.
- C. Implement precautions to prevent disease transmission.
- D. Offer the client frequent fluids and ice chips.
Correct Answer: C
Rationale: Precautions prevent infection spread.