Nokea
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.
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The nurse is triaging clients who were involved in a bus accident. Which client should be prioritized for transport to the local trauma center? A client who
- A. has pain and significant swelling in the right forearm with an intact distal pulse and sensation.
- B. has profuse bleeding from a chest laceration and is experiencing apnea.
- C. has a crushed leg reporting no sensation and has no distal pulse.
- D. is experiencing severe anxiety and has abrasions on both arms.
Correct Answer: B
Rationale: Profuse chest bleeding and apnea (B) indicate immediate life-threatening airway and circulation compromise, requiring trauma center transport. Forearm swelling (A), crushed leg (C), and anxiety (D) are serious but less acute, as they have intact vital signs or are stable.
The nurse is observing practices in the behavioral health unit. Which of the practices should the nurse question?
- A. Opening all client's postal packages prior to giving them to the client.
- B. Reviewing the process of how a client may lodge a formal complaint.
- C. Allowing clients to communicate over the telephone in a private area.
- D. Allowing clients who are involuntarily admitted to refuse prescribed medication(s).
Correct Answer: D
Rationale: Allowing involuntarily admitted clients to refuse medications (D) should be questioned, as court-ordered treatment may require compliance. Opening packages (A) ensures safety, complaint processes (B) are standard, and private calls (C) respect privacy.
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.
The nurse has received the following information about assigned clients. The nurse should first assess the client with
- A. chronic obstructive pulmonary disease (COPD) and has respiratory acidosis on the most recent arterial blood gas (ABG).
- B. atrial fibrillation taking prescribed warfarin and reports black, tarry stools.
- C. diabetes mellitus who refuses to eat following the administration of glargine insulin.
- D. acute pancreatitis and reports nausea with epigastric pain rated as a 3 on the Numerical Rating Scale.
Correct Answer: B
Rationale: Black, tarry stools in a client on warfarin (B) suggest gastrointestinal bleeding, a life-threatening complication requiring immediate assessment. Respiratory acidosis (A) is concerning but less acute if stable. Refusing to eat post-insulin (C) risks hypoglycemia but is less urgent. Pancreatitis pain (D) rated 3/10 is manageable.
The nurse is performing medication administration for four clients. Which client and medication should be administered first?
- A. Client One
- B. Client Two
- C. Client Three
- D. Client Four
Correct Answer: B
Rationale: Acetaminophen for fever (B) is the priority to address an acute symptom that may indicate infection or discomfort, requiring timely intervention. Prednisone (A), magnesium oxide (C), and glargine insulin (D) are daily medications with less immediate urgency.