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 planning client assignments for a licensed practical/vocational nurse (LPN/VN). Which client assignment would be appropriate? A client
- A. in an arm cast who is suspected to have compartment syndrome.
- B. immediately post-operative from a prostate resection reporting bladder spasms.
- C. with a paralytic ileus requiring the insertion of a nasogastric tube.
- D. newly diagnosed with Hepatitis A and requires discharge teaching.
Correct Answer: B, D
Rationale: LPNs can manage stable clients with bladder spasms post-prostate resection (B) and provide discharge teaching for Hepatitis A (D), within their scope. Compartment syndrome (A) requires RN assessment for urgent intervention, and NG tube insertion (C) is typically an RN task due to complexity.
The nurse has received a change-of-shift report for assigned clients. The nurse should initially followup on the client with
- A. cystic fibrosis who is coughing up a large amount of yellow mucus.
- B. cellulitis in the lower extremity reporting pain rated 6/10 on the Numerical Rating Scale.
- C. chronic obstructive pulmonary disease reporting blood-tinged sputum 4 hours after a bronchoscopy.
- D. dumping syndrome reporting blurred vision and disorientation.
Correct Answer: A
Rationale: Yellow mucus in cystic fibrosis (A) suggests a possible infection or exacerbation, requiring immediate assessment to prevent respiratory compromise. Cellulitis pain (B), post-bronchoscopy sputum (C), and dumping syndrome symptoms (D) are less urgent, though blurred vision in (D) warrants monitoring.
A mental health clinic is being constructed in a local community. A nurse manager is hired to facilitate the unit’s nursing policies. Which of the following is the best resource for these policies?
- A. Code of Ethics
- B. Nurse Practice Act
- C. Patient’s Bill of Rights
- D. Rights for the Mentally Ill
Correct Answer: B
Rationale: The Nurse Practice Act (B) defines legal scope and standards for nursing practice, making it the best resource for policy development. Code of Ethics (A), Patient’s Bill of Rights (C), and Rights for the Mentally Ill (D) guide but lack specific operational details.
Which statements about an electronic medical record (EMR) system are true for the nurse working in a hospital? Select all that apply.
- A. Allows for efficient and centralized documentation of patient information.
- B. Enhances communication among healthcare providers by facilitating the sharing of patient data.
- C. Improves patient safety by reducing the risk of errors in medication administration and treatment plans.
- D. Supports evidence-based practice by providing access to medical research and clinical guidelines.
- E. Eliminates the need for physical storage of paper records, reducing clutter and saving space.
Correct Answer: A, B, C, D, E
Rationale: All statements are true: EMRs centralize documentation (A), enhance provider communication (B), reduce medication and treatment errors (C), support evidence-based practice with research access (D), and eliminate paper record storage (E). These features improve efficiency, safety, and care quality in hospitals.
The nurse is demonstrating effective prioritization for assigned clients. Place the actions in the order in which they need to be performed, starting with the highest priority.
- A. Complete an incident report about a client fall that occurred three hours ago.
- B. Perform a sterile dressing change on a client with a sacral wound.
- C. Suction a client's endotracheal tube who is receiving mechanical ventilation.
- D. Administer prescribed antihypertensive medications to a client with hypertension.
- E. Administer a prescribed long-acting bronchodilator via nebulizer for a client with pneumonia.
Correct Answer: C, D, B, E, A
Rationale: 1. Suctioning an endotracheal tube (C) ensures airway patency, a life-saving priority. 2. Administering antihypertensives (D) prevents cardiovascular complications. 3. Sterile dressing change (B) prevents infection but is less urgent. 4. Bronchodilator (E) improves breathing but is long-acting, less time-sensitive. 5. Incident report (A) is administrative and not urgent.