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The nurse is caring for a client with diabetic ketoacidosis and is prescribed a bolus of regular insulin followed by a continuous infusion of regular insulin. Prior to starting the continuous infusion, the nurse administers 1 unit/kg of regular insulin to the client instead of the 0.1 unit/kg bolus. The nurse should take which initial action?
- A. Notify the primary healthcare provider (PHCP)
- B. Complete an incident report
- C. Assess the client for hypoglycemia
- D. Withhold the insulin infusion
Correct Answer: C
Rationale: Administering a 10-fold insulin overdose (C) risks severe hypoglycemia, so assessing the client immediately is critical to detect and treat low glucose. Notifying the PHCP (A), reporting (B), and withholding infusion (D) follow but are less urgent than client assessment.
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The charge nurse is in charge on a medical floor. The assignment includes a nursing assistant to transfer a client with a mechanical lift, within their scope. When the assistant says, 'I don’t know how to use the lift,' how should the nurse respond?
- A. It’s your job to know. You were trained; it’s in your description.'
- B. Your checklist shows you were competent in lifts during orientation.'
- C. Thanks for telling me. I’ll work with you to transfer safely.'
- D. No problem. I’ll reassign the transfer to another assistant.'
Correct Answer: C
Rationale: Offering to work with the assistant to transfer safely (C) ensures client safety and provides training, addressing the knowledge gap. Blaming (A), referencing past competency (B), or reassigning (D) do not promote learning or safety.
The nurse is admitting a client who is blind and deaf. The nurse should prioritize which action?
- A. Review the plan of care with the client
- B. Communicate with the nursing supervisor with any safety concerns
- C. C. Update the client on the social activities
- D. D. Provide a safe environment for the client
Correct Answer: D
Rationale: Providing a safe environment (D) is the priority for a blind and deaf client to prevent injury, using tactile communication and clear pathways. Reviewing care plans (A), addressing concerns (B), or social updates (C) are secondary to immediate safety.
The charge nurse is planning client care assignments for the medical-surgical unit. Which client should the charge nurse assign to the nurse floated from labor and delivery? A client
- A. receiving a continuous infusion of heparin for pulmonary embolism.
- B. eight hours post-operative following an open appendectomy.
- C. with a water-seal chest tube for a pneumothorax.
- D. admitted with an exacerbation of congestive heart failure (CHF).
Correct Answer: B
Rationale: A post-operative appendectomy client (B) is stable and aligns with labor and delivery nurses’ skills in post-surgical care. Heparin infusion (A), chest tube (C), and CHF exacerbation (D) require specialized medical-surgical expertise.
The nurse manager regularly performs chart audits and room inspections in the unit. They tell the staff to address the unit's deficiencies during a meeting. Which concept of management is the nurse manager displaying?
- A. Benchmarking
- B. Continuous Quality Improvement
- C. Performance Improvement
- D. Quality Management
Correct Answer: B
Rationale: Addressing deficiencies through audits and staff meetings (B) reflects continuous quality improvement, focusing on ongoing process enhancement. Benchmarking (A) compares to external standards, performance improvement (C) is specific to outcomes, and quality management (D) is broader.
The nurse is triaging clients in the emergency department (ED). Which client should the nurse triage as emergent? A client
- A. reporting pleuritic chest pain with a productive cough.
- B. who is pregnant and reporting intermittent nausea and vomiting.
- C. who has an isolated area of reddened vesicles and malaise.
- D. with sudden onset of ataxia and dysarthria.
Correct Answer: D
Rationale: Sudden ataxia and dysarthria (D) suggest a stroke, an emergent condition requiring immediate triage for time-sensitive intervention. Pleuritic cough (A), pregnancy nausea (B), and vesicles/malaise (C) are less urgent.