Nokea
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.
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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.
The nurse has learned during nursing school to maintain honesty and openness with all clients, even when conveying potentially distressing information. This approach aligns with the ethical principle of
- A. beneficence.
- B. veracity.
- C. nonmaleficence.
- D. fidelity.
Correct Answer: B
Rationale: Honesty and openness (B) align with veracity, the ethical principle of truth-telling. Beneficence (A) promotes well-being, nonmaleficence (C) avoids harm, and fidelity (D) keeps promises, but veracity is most relevant here.
The nurse is caring for four clients on a medical-surgical unit. Which of the following tasks would be a priority for the nurse to complete?
- A. teaching a client scheduled for discharge how to ambulate with crutches
- B. witnessing informed consent for a client needing an emergency laparotomy
- C. irrigating a client's ostomy who reports abdominal cramping
- D. calculating the intake and output of a client with diabetes insipidus (DI)
Correct Answer: B
Rationale: Witnessing informed consent for an emergency laparotomy (B) is a priority, as it ensures legal and ethical requirements are met for urgent surgery. Crutch training (A), ostomy irrigation (C), and intake/output calculation (D) are important but less time-sensitive.
The nurse is caring for a client admitted for an exacerbation of Meniere’s disease. Which of the following nursing interventions is of the highest priority when caring for this client?
- A. Determining if the client has experienced hearing loss.
- B. Initiating fall risk measures.
- C. Ensuring adherence to a low-sodium diet.
- D. Administering prescribed anticholinergic medications.
Correct Answer: B
Rationale: Initiating fall risk measures (B) is the highest priority in Meniere’s exacerbation due to vertigo, which poses an immediate safety risk. Hearing loss assessment (A), low-sodium diet (C), and medications (D) are important but secondary to preventing falls.
The nurse has received a telephone prescription from the primary healthcare provider (PHCP) for citalopram 10 mg PO daily. Which action is the nurse's priority while taking the telephone order?
- A. Verify that the medication is in stock
- B. Read back the prescription to the PHCP
- C. Inform the client of the new prescription
- D. Transmit the prescription to the pharmacy
Correct Answer: B
Rationale: Reading back the prescription to the PHCP (B) is the priority to ensure accuracy and prevent medication errors, a critical safety step in taking telephone orders. Verifying stock (A), informing the client (C), and transmitting to the pharmacy (D) are important but follow confirmation of the order’s correctness.