Nokea
The nurse recognizes that the most effective way to resolve a conflict is through
- A. compromising.
- B. accommodating.
- C. avoiding.
- D. a win-win solution.
Correct Answer: D
Rationale: A win-win solution (D) resolves conflict by addressing all parties’ needs, fostering collaboration and long-term resolution. Compromising (A) and accommodating (B) may leave issues unresolved, and avoiding (C) delays resolution.
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The nurse is caring for assigned clients. Which of the following actions would reflect effective care coordination? Select all that apply.
- A. Arranging for an interdisciplinary conference
- B. Consulting with case management for a discharge plan
- C. Initiating appropriate outpatient referrals
- D. Performing post-discharge phone calls
- E. Implementing transmission-based precautions
Correct Answer: A, B, C, D
Rationale: Effective care coordination includes interdisciplinary conferences (A), case management for discharge (B), outpatient referrals (C), and post-discharge follow-up (D). Transmission precautions (E) are infection control, not care coordination.
The nurse is caring for assigned clients with newly received prescriptions. Which prescription should the nurse administer first? See the exhibit.
- A. Levofloxacin 750 mg IVPB Q12 hours
- B. 0.9% Saline 125 ml/hr
- C. Metoclopramide 10 mg IV Push Q8 hours
- D. Ketorolac 15 mg IV Push Q8 hours
Correct Answer: A
Rationale: Pneumonia in an elderly client can be particularly severe due to age-related immune system decline and potential for complications like acute respiratory distress syndrome (ARDS) and/or sepsis.
The nurse is caring for the following assigned clients. The nurse should prioritize following up with the client
- A. who had a myocardial infarction two days ago, and has an elevated troponin level.
- B. with infective endocarditis who wants to leave against medical advice (AMA).
- C. who has arterial insufficiency and is reporting leg pain after walking in the hall.
- D. recovering from cardiac catheterization, who has developed atrial fibrillation.
Correct Answer: D
Rationale: Atrial fibrillation post-cardiac catheterization (D) is a new, potentially unstable arrhythmia requiring immediate follow-up. Elevated troponin (A) is expected post-MI, AMA (B) needs discussion, and leg pain (C) is less urgent.
The emergency department (ED) nurse is caring for a client who just arrived with a major thermal burn to 22.5% of the total body surface area (TBSA). Place the following actions in the order in which they need to be performed, starting from first to last.
- A. Establish a large bore peripheral vascular access device to unburned skin.
- B. Insert an indwelling urinary catheter to maintain urinary output 0.5 mL/kg/hr.
- C. Administer tetanus prophylaxis as prescribed.
- D. Administer supplemental oxygen if indicated and cover burns with sterile gauze.
- E. Assess the client's airway, breathing, and circulation and obtain vital signs.
- F. Administer prescribed isotonic fluids intravenously to maintain fluid balance.
Correct Answer: E, D, A, F, B, C
Rationale: Initial assessment of airway, breathing, circulation (E) ensures stability, followed by oxygen and burn coverage (D) for hypoxia prevention. IV access (A) and fluids (F) address shock, catheter insertion (B) monitors output, and tetanus prophylaxis (C) is last, as it’s preventive.
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.