Nokea
The nurse on the medical-surgical unit has received two new client admissions simultaneously. Which assessment is essential to determine which client the nurse should see first?
- A. Vital signs
- B. Number of prescribed medications
- C. Medical history
- D. Code status
Correct Answer: A
Rationale: Vital signs (A) are essential to determine which new admission to assess first, as they indicate immediate physiological stability or instability. Medications (B), medical history (C), and code status (D) are important but secondary to detecting life-threatening conditions.
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The nurse triages phone calls for the primary healthcare provider (PHCP). Which client report requires immediate follow-up? A client reporting
- A. bilateral flank pain who has two nephrostomy tubes.
- B. abdominal cramping while instilling dialysate for peritoneal dialysis (PD).
- C. facial edema while being treated for nephrotic syndrome.
- D. a localized rash following the administration of ciprofloxacin for cystitis.
Correct Answer: C
Rationale: Facial edema in nephrotic syndrome (C) suggests worsening hypoalbuminemia or fluid overload, a medical emergency requiring immediate follow-up. Flank pain (A), dialysis cramping (B), and rash (D) are less urgent, as they are expected or manageable.
The registered nurse (RN) is observing licensed practical/vocational nurses (LPN/VN) care for assigned clients. Which of the following actions by the LPN would require the RN to intervene? Select all that apply.
- A. Positions an unconscious client semi-Fowlers for oral care
- B. Administers a bronchodilator to a client with chronic asthma
- C. Irrigates an indwelling urinary catheter with 30 ml of sterile saline
- D. Removes and reapplies weight to a client's skin traction every two hours
- E. Administers intramuscular (IM) ketorolac to a client with osteoarthritis
Correct Answer: A
Rationale: Positioning an unconscious client in semi-Fowler’s for oral care (A) risks aspiration, requiring intervention. Bronchodilator (B), catheter irrigation (C), traction adjustment (D), and ketorolac administration (E) are within LPN scope if per protocol.
The nurse is researching evidence-based practice and needs related literature. The nurse understands that the best source of reliable writing is:
- A. Systematic review and meta-analysis studies
- B. Expert opinions
- C. Qualitative studies
- D. Case studies
Correct Answer: A
Rationale: Systematic reviews and meta-analyses (A) provide the highest level of evidence by synthesizing multiple studies, per evidence-based practice hierarchies. Expert opinions (B), qualitative studies (C), and case studies (D) are less reliable due to subjectivity or limited scope.
The nurse is caring for assigned clients. The nurse should initially assess the client who has
- A. left pulmonary empyema, a temperature of 102.4°F (39.1°C), and a pulse of 104.
- B. gentle bubbling in the water seal chamber of their chest tube when exhaling.
- C. a right pleural effusion and has decreased tactile fremitus in the right lobe.
- D. pneumonia and has a pulse oximetry of 90% while on 4 liters of nasal cannula oxygen.
Correct Answer: A
Rationale: Fever (102.4°F) and tachycardia (104) in empyema (A) suggest worsening infection or sepsis, requiring immediate assessment. Chest tube bubbling (B) is normal, pleural effusion findings (C) are expected, and 90% saturation (D) is stable with oxygen.
The nurse has received the following prescriptions for newly admitted clients. Which prescription should the nurse administer first?
- A. Aspirin to a client experiencing an acute myocardial infarction
- B. Lisinopril to a client with essential hypertension
- C. Risperidone to a client with schizophrenia
- D. Levodopa-carbidopa to a client with Parkinson's disease
Correct Answer: A
Rationale: Aspirin for acute myocardial infarction (A) is the priority to reduce thrombus formation and mortality, per ACS guidelines. Lisinopril (B), risperidone (C), and levodopa-carbidopa (D) address chronic conditions and are less urgent.