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The nurse working on a medical-surgical unit is caring for assigned clients. The nurse should plan to initially assess the client who
- A. had a subtotal thyroidectomy 12 hours ago and reports difficulty swallowing.
- B. reports increased pain following a sterile dressing change for a stage IV pressure ulcer.
- C. has bilateral lower lobe pneumonia and has not used the incentive spirometer in six hours.
- D. is scheduled for an adrenalectomy in eight hours and has not signed the informed consent.
Correct Answer: A
Rationale: Difficulty swallowing post-thyroidectomy (A suggests complications like hematoma or nerve injury, which can be life-threatening and require immediate assessment. Increased pain (B), and not using an incentive spirometer (C), and lack of consent (D) are less urgent and critical.
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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 is educating staff on adult basic life support. It would be appropriate to include which of the following? Select all that apply.
- A. Carotid pulse check should not take more than 20 seconds.
- B. The rate of chest compressions should be 100-120 per minute.
- C. Chest compression depth should be 2 inches on the center breastbone.
- D. Chest tube insertion should be prepared after five minutes of CPR.
- E. Early defibrillation is essential in the survival of ventricular fibrillation.
Correct Answer: B, E
Rationale: Chest compression rate of 100-120/minute (B) and early defibrillation for ventricular fibrillation (E) are correct per AHA guidelines. Pulse check is ≤10 seconds (A), depth is ~2.4 inches (C), and chest tube insertion (D) is not part of BLS.
The nurse has received the following prescriptions for newly admitted clients. Which medication should the nurse administer first?
- A. Subcutaneous (SubQ) epoetin for anemia
- B. oxycodone by mouth (PO) for pain control
- C. Intravenous (IV) fluids for sepsis
- D. Intramuscular (IM) hydroxyzine for anxiety
Correct Answer: C
Rationale: IV fluids for sepsis (C) are the priority to restore perfusion and prevent organ failure. Epoetin (A) addresses chronic anemia, oxycodone (B) manages pain, and hydroxyzine (D) treats anxiety, all less urgent than sepsis.
The nurse is teaching a group of students about incident reports. Which of the following situations would require an incident report? A visitor. Select all that apply.
- A. refusing to wear personal protective equipment (PPE).
- B. adjusting a client's infusion pump.
- C. requesting that their family member get pain medication.
- D. assisting their family member with brushing their teeth.
- E. stating that they fell while using the bathroom.
Correct Answer: A, B, E
Rationale: Refusing PPE (A), adjusting an infusion pump (B), and falling in the bathroom (E) are safety incidents requiring reports, as they pose risks or indicate harm. Requesting pain medication (C) and assisting with tooth brushing (D) are not reportable unless escalated.
The nurse has several tasks that need to be completed. Which of the following client assignments would be appropriate to delegate to the unlicensed assistive personnel?
- A. A 65-year-old male requiring sterile dressing changes.
- B. A 26-year-old female requiring a one-person assist in ambulating to the restroom.
- C. An 80-year-old male who is receiving enteral feedings continuously through an NG tube.
- D. A 23-year-old client requiring frequent urinary specimen collections from their indwelling urinary catheter.
Correct Answer: B
Rationale: Assisting a client with ambulation (B) is a non-clinical task within the UAP’s scope. Sterile dressing changes (A), enteral feedings (C), and catheter specimen collection (D) require clinical judgment or training beyond UAP scope.