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Which healthcare team member is paired with the primary function related to their role?
- A. An occupational therapist assisting with gait exercises.
- B. A physical therapist offers the provision of assistive devices to be used with activities of daily living.
- C. A speech or language therapist addressing swallowing disorders.
- D. An RN case manager ordering therapies and medications.
Correct Answer: C
Rationale: A speech or language therapist addressing swallowing disorders (C) is correctly paired, as this is their primary role. Occupational therapists (A) focus on daily living activities, not gait. Physical therapists (B) focus on mobility, not assistive devices primarily. RN case managers (D) coordinate care, not order therapies/medications.
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The nurse overhears an unlicensed assistive personnel (UAP) shout at a client, 'you will have to get a feeding tube if you do not start eating more at mealtimes.' The nurse recognizes that the UAP has Select all that apply.
- A. committed battery.
- B. engaged in unprofessional conduct.
- C. committed assault.
- D. been negligent.
- E. demonstrated libel.
Correct Answer: B, C
Rationale: Shouting and threatening a feeding tube (B, C) constitutes unprofessional conduct (B) and assault (C), a verbal threat of harm. Battery (A) requires physical contact, negligence (D) involves failure of duty, and libel (E) is written defamation, none of which apply.
The nurse from the medical-surgical unit is calling a telephone report to the cardiac intensive care unit nurse regarding a client who is being transferred for a change in condition. Using the identification, situation, background, assessment, and recommendation (ISBAR) format, place the following communication steps in the order in which they should be performed, starting from first to last.
- A. He is a 56-year-old male admitted two days ago with community-acquired pneumonia. He has a medical history of diabetes mellitus and depression.
- B. His most recent vital signs were blood pressure 160/100, pulse 113, respirations 30, temperature 99, and oxygen saturation 89%. He is experiencing significant dyspnea and substernal chest pain radiating to the arm. The 12-lead electrocardiogram showed ST-elevation in two leads. Nasal cannula oxygen was applied, and 2 mg of IV morphine was given.
- C. Mr. Joe Smith is being transferred because he has trouble breathing and reports chest pain not relieved with nitroglycerin.
- D. Dr. Adams ordered a transfer because of confirmed myocardial infarction and to be treated with intravenous thrombolytics. When he arrives at the unit, he has an order for intravenous nitroglycerin infusion.
- E. I am the medical-surgical nurse calling to report about Mr. Joe Smith, the client being transferred with acute coronary syndrome.
Correct Answer: E, C, A, B, D
Rationale: Using ISBAR: 1. Identification (E) introduces the nurse and client. 2. Situation (C) outlines the current issue (chest pain, dyspnea). 3. Background (A) provides history. 4. Assessment (B) details vital signs and findings. 5. Recommendation (D) includes transfer orders and next steps.
The emergency department (ED) nurse cares for a client who presents with irritability, nuchal rigidity, and a fever. Which of the following actions should the nurse take first?
- A. Administer prescribed ibuprofen.
- B. Place the client on droplet precautions.
- C. Notify the public health department.
- D. Obtain prescribed blood cultures.
Correct Answer: B
Rationale: Placing the client on droplet precautions (B) is the first action for suspected meningitis (irritability, nuchal rigidity, fever) to prevent spread of infection. Administering ibuprofen (A), notifying public health (C), and obtaining blood cultures (D) are important but secondary to infection control.
The nurse has attended a staff education program about incident reporting. It would indicate effective understanding if the nurse states that the primary purpose of incident reporting is to
- A. implement corrective measures needed to prevent recurrence.
- B. collect data about errors and compare it to different time periods.
- C. communicate the error(s) to other departments within the facility.
- D. notify the individual involved of the deviation from the standard of care.
Correct Answer: A
Rationale: The primary purpose of incident reporting (A) is to implement corrective measures to prevent recurrence, enhancing client safety. Data collection (B), interdepartmental communication (C), and individual notification (D) are secondary benefits of the reporting process.
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.