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Which of the following is the first nursing action for a patient experiencing dyspnea?
- A. Remove pillows from under the patient's head
- B. Elevate the head of the bed
- C. Elevate the foot of the bed
- D. Take the patient's blood pressure
Correct Answer: B
Rationale: Elevating the head of the bed (B) is the first action for dyspnea to improve lung expansion and ease breathing. Removing pillows (A) may worsen discomfort, elevating the foot (C) is irrelevant, and taking blood pressure (D) is secondary.
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The nurse is conducting a staff education program about hand-off reports for clients in an acute care environment. Which of the following should be included during the hand-off report? Select all that apply.
- A. emergency code status
- B. allergies
- C. home medications
- D. admitting diagnosis
- E. review of previous hospitalizations
- F. health insurance status
Correct Answer: A, B, C, D
Rationale: Code status (A), allergies (B), home medications (C), and admitting diagnosis (D) are critical for safe care transitions per ISBAR standards. Previous hospitalizations (E) and insurance status (F) are not essential for immediate handoff.
The nurse is caring for a group of clients in the labor and delivery department. The nurse should prioritize assessing the client who
- A. is 39 weeks gestation with regular contractions every 3 minutes and reports perineal pressure.
- B. had an epidural placed 3 hours ago and reports a mild headache and has a distended bladder.
- C. delivered a term newborn 4 hours ago and has saturated one peri-pad since delivery and has a temperature of 99.6°F (37.6°C).
- D. is 37 weeks gestation with blood pressure 168/112 mmHg, reports a persistent headache.
Correct Answer: D
Rationale: Severe hypertension (168/112 mmHg) with headache at 37 weeks (D) suggests preeclampsia, a life-threatening emergency requiring immediate assessment to prevent seizures or organ damage. Perineal pressure (A), epidural headache (B), and postpartum findings (C) are less urgent.
The nurse is triaging phone calls at the physician’s office. The nurse should initially follow-up on the client who had
- A. cataract lens extraction one day ago and is reporting persistent nausea and vomiting.
- B. laparoscopic hysterectomy two days ago and is reporting pain with urination.
- C. ileostomy placement three days ago and is reporting that the stoma is swollen.
- D. total hip arthroplasty four days ago and refused physical therapy due to increased pain.
Correct Answer: A
Rationale: Persistent nausea and vomiting post-cataract surgery (A) suggest possible complications like increased intraocular pressure, requiring immediate follow-up. Dysuria (B), stoma swelling (C), and therapy refusal (D) are less urgent, as they are common or non-emergent.
The nurse is providing discharge instructions to a client who speaks a language different from the nurse's. The client's family members are present, and they speak English. Which action by the nurse is the most appropriate to ensure effective communication during the discharge process?
- A. Use a smartphone translation app to convey the instructions to the client.
- B. Provide written material in the client's language and provide oral instructions in English.
- C. Request an interpreter from the hospital's language services to assist with the discharge instructions.
- D. Summarize the instructions in basic English and have the family members relay the information to the client.
Correct Answer: C
Rationale: Using a professional interpreter (C) ensures accurate communication, adhering to legal and ethical standards for discharge teaching. Smartphone apps (A) are unreliable, written material with English oral instructions (B) is ineffective, and relying on family (D) risks misinterpretation.
The medical-surgical nurse is assigned to the intensive care unit (ICU). The nurse accepts the hand-off reports and indicates they are not qualified to provide the necessary care. It would be appropriate for the medical-surgical nurse to take which action?
- A. Refuse to provide any client care
- B. Document the concern in the client's medical record
- C. Notify the primary healthcare provider (PHCP)
- D. Report the concerns to the nursing supervisor
Correct Answer: D
Rationale: Reporting concerns to the nursing supervisor (D) ensures safe staffing and reassignment, protecting clients and the nurse. Refusing care (A) is unprofessional, documenting in records (B) is inappropriate, and notifying the provider (C) is not the nurse’s role.