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The emergency department (ED) nurse is caring for a client admitted with diabetic ketoacidosis (DKA). Which clinical data requires immediate follow-up?
- A. Respiratory rate (RR) 23/minute
- B. Capillary blood glucose 319 mg/dL (17.70 mmol/L) [70-110 mg/dL, 4.0-11.0 mmol/L]
- C. Mean arterial pressure (MAP) 51 mm Hg
- D. PaO2 90 mm Hg [80-100 mm Hg]
Correct Answer: C
Rationale: A MAP of 51 mm Hg in DKA (C) indicates severe hypotension and organ hypoperfusion, requiring immediate fluid resuscitation. RR 23 (A) and glucose 319 (B) are expected in DKA, and PaO2 90 (D) is normal, none requiring immediate action.
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The emergency department (ED) nurse is caring for a client brought in after being found walking around a neighborhood without shoes, confused and disoriented. The nurse should initially
- A. obtain vital signs.
- B. perform a mental status exam.
- C. attempt to locate the client’s family.
- D. request an order for a psychiatry consultation.
Correct Answer: A
Rationale: Obtaining vital signs (A) is the initial priority to assess for physiological instability (e.g., hypothermia, hypoglycemia) in a confused client. Mental status exam (B), family contact (C), and psychiatry consult (D) follow after ensuring medical stability.
A nurse observes a colleague failing to perform hand hygiene before entering multiple client rooms and administering medications. What is the most appropriate action by the nurse?
- A. Confront the colleague immediately in a client's room to stop the behavior
- B. Document the incident in the nurse's notes while monitoring for further issues
- C. Immediately report the behavior to the nurse manager for follow-up
- D. Assume the colleague is having a busy shift, and address it at a later time
Correct Answer: C
Rationale: Reporting to the nurse manager (C) ensures prompt follow-up on a serious infection control breach that risks client safety. Confronting in a client’s room (A) is unprofessional, documenting without action (B) delays intervention, and assuming busyness (D) ignores the safety violation.
The registered nurse (RN) is orienting a new RN to the charge nurse role. When delegating tasks, which task delegated to the licensed practical/vocational nurse (LPN/VN) would require follow-up from the charge nurse?
- A. Obtaining an occult stool sample for a client with ulcerative colitis.
- B. Assessing a newly admitted client with chest pain.
- C. Reinforcing teaching to a client newly diagnosed with diabetes mellitus.
- D. Providing pin care for a client with external fixation of the wrist.
Correct Answer: B
Rationale: Assessing a new client with chest pain (B) requires RN-level judgment due to potential life-threatening conditions, necessitating follow-up if delegated to an LPN. Stool sample collection (A), reinforcing teaching (C), and pin care (D) are within LPN scope.
The nurse in the emergency department (ED) is caring for a client and establishes continuous cardiac monitoring. Which initial action should the nurse take based on the electrocardiogram tracing? See the exhibit for additional client information.
- A. Establish vascular access and request a prescription for atropine
- B. Assess the client's blood pressure and level of consciousness
- C. Obtain and review the client's current medications
- D. Document the findings and reassess the client in one hour
Correct Answer: B
Rationale: Sinus bradycardia can be benign or symptomatic. The priority is to determine whether the client is hemodynamically stable by assessing blood pressure (BP) and level of consciousness (LOC). If the client is symptomatic (e.g., hypotension, dizziness, altered mental status), further interventions such as atropine administration may be required.
The nurse is providing the client with information regarding advanced directives. The nurse understands that giving this information supports the client's
- A. right to privacy.
- B. right to emergency care regardless of the ability to pay.
- C. C. self-determination.
- D. D. ability to receive appropriate treatment for their pain.
Correct Answer: C
Rationale: Advance directive discussions support self-determination (C) by empowering clients to make healthcare decisions. Privacy (A), emergency care (B), and pain treatment (D) are not directly related to advance directives.