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The client diagnosed with septicemia is receiving a broad-spectrum antibiotic. Which laboratory data require the nurse to notify the health-care provider?
- A. The client’s potassium level is 3.8 mEq/L.
- B. The urine culture indicates high sensitivity to the antibiotic.
- C. The client’s pulse oximeter reading is 94%.
- D. The culture and sensitivity is resistant to the client’s antibiotic.
Correct Answer: D
Rationale: Antibiotic resistance requires immediate HCP notification to adjust therapy. Normal potassium, sensitive cultures, and 94% SpO2 are not urgent.
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The ED nurse is caring for a male client admitted with carbon monoxide poisoning. Which intervention requires the nurse to notify the rapid response team?
- A. The client has expectorated black sputum.
- B. The client reports trying to kill himself.
- C. The client’s pulse oximeter reading is 94%.
- D. The client has stridor and reports dizziness.
Correct Answer: D
Rationale: Stridor indicates airway obstruction, and dizziness suggests worsening CO toxicity, requiring rapid response. Black sputum, suicidal intent, and 94% SpO2 are less acute.
The client with a temperature of 94°F is being treated in the ED. Which intervention should the nurse implement to directly elevate the client’s temperature?
- A. Remove the client’s clothing.
- B. Place a warm air blanket over the client.
- C. Have the client change into a hospital gown.
- D. Raise the temperature in the room.
Correct Answer: B
Rationale: A warm air blanket (e.g., Bair Hugger) directly raises core temperature in hypothermia. Removing clothing, changing gowns, or room temperature are less effective.
The client in a code is now in ventricular bigeminy. The HCP orders a lidocaine drip at three (3) mg/min. The lidocaine comes prepackaged with two (2) grams of lidocaine in 500 mL of D5W. At which rate will the nurse set the infusion pump?
Correct Answer: 45
Rationale: Lidocaine concentration: 2 g = 2000 mg in 500 mL = 4 mg/mL. Dose: 3 mg/min. Rate = (3 mg/min) / (4 mg/mL) = 0.75 mL/min = 45 mL/hour (0.75 * 60). Pump set to 45 mL/hour.
The health-care facility has been notified an alleged inhalation anthrax exposure has occurred at the local post office. Which category of personal protective equipment (PPE) should the response team wear?
- A. Level A.
- B. Level B.
- C. Level C.
- D. Level D.
Correct Answer: C
Rationale: Level C PPE (respirator and protective suit) is appropriate for inhalation anthrax, balancing protection and mobility. Level A is for highest risk, Level B for chemical hazards, and Level D is minimal.
Which problem is most appropriate for the nurse to identify for the client experiencing renal trauma?
- A. Infection of the renal tract.
- B. Ineffective tissue perfusion.
- C. Alteration in skin integrity.
- D. Alteration in temperature.
Correct Answer: B
Rationale: Renal trauma risks bleeding and hypoperfusion, making ineffective tissue perfusion the primary problem. Infection, skin integrity, and temperature are less immediate.