Extract:

Question 1 of 5

A nurse in an emergency department is assisting with the care of a client who reports chest pain and shortness of breath. Which of the following actions should the nurse take first?

A. Administer oxygen at 2 L/min via nasal cannula.B. Obtain a 12-lead ECG.C. Administer nitroglycerin sublingually.D. Insert an IV catheter.

Correct Answer: B

Rationale: An ECG first assesses for cardiac ischemia or infarction, guiding urgent treatment. Oxygen, nitroglycerin, and IV access follow based on findings.

Question 2 of 5

A nurse is assisting with the care of a client who is at risk for falls. Which of the following actions should the nurse take?

A. Keep the client's bed in the highest position.B. Ensure the client wears socks while ambulating.C. Place a fall risk identification band on the client's wrist.D. Instruct the client to call for assistance before getting out of bed.

Correct Answer: D

Rationale: Calling for assistance reduces fall risk by ensuring support. High beds, socks only, and no band alone increase risk without addressing immediate safety.

Question 3 of 5

A nurse is reinforcing teaching with a client who has hypertension and a new prescription for verapamil. Which of the following statements should the nurse include?

A. You should avoid eating grapefruit while taking this medication.B. This medication might cause you to gain weight.C. You might notice that this medication causes your gums to bleed.D. You might experience an increase in your energy level while taking this medication.

Correct Answer: A

Rationale: Verapamil interacts with grapefruit, increasing drug levels and side effects. Weight gain, gum bleeding, and energy boosts aren't typical effects.

Question 4 of 5

A nurse is collecting data from a client who has a long leg cast on his left leg. Which of the following findings is the priority?

A. Ecchymosis on the inner left thighB. One fingerbreadth of space between the cast and the skinC. Diminished pulses on the affected extremityD. Client report of muscle spasms of the left leg

Correct Answer: C

Rationale: Diminished pulses indicate potential circulatory compromise, a priority requiring immediate intervention. Ecchymosis may resolve, space is normal, and spasms are less urgent.

Question 5 of 5

A nurse is contributing to an in-service for newly licensed nurses about situations requiring an incident report. Which of the following examples should the nurse include?

A. A nurse observes a client vomiting after receiving an oral pain medication.B. A nurse observes another nurse remove wrist restraints one at a time from a client who is currently calm.C. A nurse discovers that an electronic IV pump delivered twice the prescribed amount of fluid to a client.D. A nurse discovers that a client's family member has administered a PCA dose.

Correct Answer: C

Rationale: An IV pump error delivering double the fluid is a serious medication error requiring an incident report. Vomiting is a side effect, restraint removal may not need reporting, and PCA misuse needs clarification.