Nokea
The nurse preceptor is observing a newly hired nurse care for assigned clients. It would require follow-up by the nurse preceptor if the newly hired nurse is observed doing which of the following?
- A. Humidifies nasal cannula oxygen for a client with sarcoidosis.
- B. Secures a suprapubic catheter tubing to a client’s inner thigh.
- C. Places a client with varicella-zoster in airborne and contact isolation.
- D. Suctions a tracheostomy for 10 seconds as they remove the catheter.
Correct Answer: D
Rationale: Suctioning a tracheostomy for 10 seconds (D) risks hypoxia and trauma, requiring follow-up as it should be brief (5-10 seconds max). Humidifying oxygen (A), securing catheters (B), and isolating varicella (C) are correct practices.
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The nurse is planning care for a client being admitted with cardiac dysrhythmias. When planning care for this client, the nurse should prioritize
- A. auscultating heart tones.
- B. establishing continuous electrocardiogram (ECG) monitoring.
- C. obtaining vital signs.
- D. establishing a secondary peripheral vascular access device.
Correct Answer: B
Rationale: Continuous ECG monitoring (B) is the priority for cardiac dysrhythmias to detect and manage life-threatening arrhythmias in real-time. Auscultating heart tones (A), vital signs (C), and IV access (D) are important but secondary to monitoring.
A client has used a condescending tone towards the nurse, subsequently angering the nurse. Which response by the nurse would be most therapeutic?
- A. That tone of voice makes me feel upset.'
- B. You make me angry when you talk like that.'
- C. Are you trying to upset me?'
- D. Why do you use that tone of voice with me?'
Correct Answer: A
Rationale: Expressing feelings using 'I' statements (A) is therapeutic, promoting open communication without blame. Blaming the client (B), assuming intent (C), or questioning their tone (D) escalates conflict and is non-therapeutic.
The nurse is caring for a client one day post-operative following a left hip arthroplasty. Which assessment finding requires immediate follow-up?
- A. Restlessness
- B. Blood glucose 155 mg/dL (8.61 mmol/L) [70 to 110 mg/dL]
- C. Temperature 99.7°F (37.6°C)
- D. Pain with movement in the left leg
Correct Answer: A
Rationale: Restlessness post-hip arthroplasty (A) may indicate complications like hypoxia, bleeding, or dislocation, requiring immediate intervention. Glucose elevation (B), mild fever (C), and pain with movement (D) are expected or less urgent.
The nurse reviews the client's emergency department (ED) triage note. Which action should the nurse take first? See the image below.
- A. Establish continuous cardiac monitoring
- B. Obtain an order for a complete metabolic panel
- C. Obtain a prescription for acetaminophen (APAP)
- D. Apply a cool compress to the client's forehead
Correct Answer: A
Rationale: This client is showing manifestations of digitalis toxicity. The client's bradycardia, anorexia, and vomiting are classic signs of this potentially fatal toxicity. The nurse should immediately establish continuous cardiac monitoring because, if untreated, digitalis toxicity may cause multifocal premature ventricular contractions (PVCs) that may transition to ventricular tachycardia or ventricular fibrillation. Because of digitalis' ability to have a negative chronotropic effect, bradycardia is often seen in toxicity.
The nurse is caring for assigned clients. Which of the following activities should the nurse perform first?
- A. administer acetaminophen to a client with a temperature of 101.1°F (38.4°C)
- B. complete pin care for a client with a halo fixation device
- C. administer diazepam for a client with delirium tremens (DTs)
- D. insert an indwelling urinary catheter for a client with retention
Correct Answer: C
Rationale: Administering diazepam for delirium tremens (C) is the priority to prevent seizures and life-threatening complications. Fever treatment (A), pin care (B), and catheter insertion (D) are less urgent, as they address stable or less critical conditions.