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The nurse works with others inside and outside their immediate work environment to achieve goals and make decisions that reflect the best interest for their clients. Which best describes the role the nurse is fulfilling in this capacity? The nurse is acting as a
- A. collaborator
- B. team leader
- C. delegator
- D. manager
Correct Answer: A
Rationale: Collaborating with others across settings to achieve client-centered goals (A) defines the nurse’s role as a collaborator. Team leader (B) focuses on directing a group, delegator (C) assigns tasks, and manager (D) oversees operations, none of which fully capture this role.
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The nurse is preparing medications for the shift. Which of the following clients should the nurse prioritize for immediate medication administration?
- A. Digoxin to a client with atrial fibrillation
- B. Furosemide to a client with congestive heart failure
- C. Magnesium sulfate to a client with Torsades de pointes
- D. Labetalol to a client with a blood pressure of 160/100 mmHg
Correct Answer: C
Rationale: Magnesium sulfate for Torsades de pointes (C) is the priority to stabilize life-threatening ventricular arrhythmias, per ACLS guidelines. Digoxin (A), furosemide (B), and labetalol (D) address less acute conditions.
The nurse has become aware of the following client situations. The nurse should first follow up with which client? A client
- A. with a chest tube that has tidaling in the water seal chamber.
- B. that is receiving mechanical ventilation and is occasionally biting on the tube.
- C. that is receiving albuterol via a nebulizer and reports headache and nervousness.
- D. with pneumonia that has become restless and confused.
Correct Answer: D
Rationale: Restlessness and confusion in pneumonia (D) suggest hypoxia or worsening infection, requiring immediate follow-up to prevent deterioration. Chest tube tidaling (A) is normal, tube biting (B) is concerning but less acute, and albuterol side effects (C) are expected.
The client has just been given an IV dose of morphine 6 mg for neuropathic pain. A few minutes later, the nurse notes that the client's respirations are now 8, and his blood pressure has dropped from 122/83 mmHg to 88/67 mmHg. Which nursing action is the most appropriate?
- A. Prepare for intubation.
- B. Prepare to administer a dopamine infusion.
- C. Administer naloxone.
- D. Start an IV infusion of normal saline.
Correct Answer: C
Rationale: Respiratory depression (RR 8) and hypotension post-morphine (C) indicate opioid overdose, requiring naloxone to reverse effects, per ACLS guidelines. Intubation (A), dopamine (B), and saline (D) are secondary or inappropriate without reversal.
The nurse is reviewing the plan of care for a client admitted to the behavioral health unit with anorexia nervosa. The nurse understands that the priority goal for this client is
- A. attending scheduled group therapy.
- B. adhere to the medication regimen.
- C. gain one pound (half a kilogram) a week.
- D. demonstrate increased self-esteem.
Correct Answer: C
Rationale: Gaining one pound (half a kilogram) per week (C) is the priority goal for anorexia nervosa to address life-threatening malnutrition and stabilize physical health. Attending group therapy (A), adhering to medications (B), and improving self-esteem (D) are important but secondary to restoring nutritional status to prevent organ failure.
The nurse is triaging a client involved in a chemical spill at a local chemical plant. The nurse assesses the client as responsive but unable to walk, with a respiratory rate of 28 and capillary refill <2 seconds. It would be correct for the nurse to triage this client with a
- A. yellow tag.
- B. red tag.
- C. black tag.
- D. green tag.
Correct Answer: A
Rationale: A yellow tag (A) is appropriate for a responsive client unable to walk with stable vital signs (RR 28, capillary refill <2 sec), indicating urgent but not immediate life-threatening needs. Red (B) is for critical, black (C) for deceased, and green (D) for minor injuries.