Nokea
Laboratory reference ranges
Glucose (random)
71-200 mg/dL
(3.9-11.1 mmol/L)
A category 4 hurricane has affected a rural, local health care system, creating a significant increase in emergency department admissions. Which of the following clients should the nurse anticipate as the priority for intervention?
- A. Client with status asthmaticus and a pulse oximetry reading of 89%
- B. Client with diabetes mellitus reporting a headache after being involved in a minor motor vehicle collision
- C. Client who is 11 weeks pregnant, has gestational diabetes, and nausea and vomiting over the past 2 days
- D. Client with diabites mellitus with a serum glucose level of 690 mg/dl (38.3 mmol/L ,abdominal pain, and fatigue)
Correct Answer: A
Rationale: Status asthmaticus with 80% pulse oximetry (A) indicates severe hypoxia, requiring immediate intervention to prevent respiratory failure. Headache post-collision (B) and nausea in pregnancy (C) are less acute, as they do not indicate immediate life-threatening conditions.
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A client with poorly controlled diabetes mellitus gives birth to a newborn at term gestation. When caring for the 2 hour-old newborn, which clinical finding requires the nurse to intervene?
- A. Cyanosis of hands and feet
- B. Heart rate of 165/min while crying
- C. Jitteriness
- D. Respirations of 60/min
Correct Answer: C
Rationale: Jitteriness (C) in a newborn of a diabetic mother suggests hypoglycemia, a common complication due to maternal hyperglycemia causing fetal hyperinsulinism. Immediate intervention (e.g., glucose testing) is needed. Acrocyanosis (A) is normal, heart rate 165/min while crying (B) is within range, and respirations of 60/min (D) are normal for a newborn.
At 26 weeks gestation, a client is admitted to the ER stating that she has been having a painless bloody vaginal discharge since last evening. The nurse should give priority to:
- A. Reporting the findings to the physician
- B. Evaluating the color of the discharge
- C. Evaluating the client's vital signs
- D. Applying an external fetal monitor
Correct Answer: A
Rationale: Painless bleeding at 26 weeks suggests placenta previa or abruption, requiring immediate physician notification . Assessing discharge , vitals , or fetal monitoring follows reporting.
The doctor has ordered Nitrostat (nitroglycerine) sublingually for a client with angina. The client should be ordered to replenish his supply every:
- A. 6 months
- B. 3 months
- C. 12 months
- D. 18 months
Correct Answer: A
Rationale: Nitroglycerin loses potency after 6 months, requiring replacement to ensure efficacy for angina relief.
During the charge nurse’s morning rounds, a client says, 'I hope you will take better care of me than the nurse I had last night.' What should be the charge nurse’s initial response?
- A. Apologize for the previous nurse’s treatment
- B. Ask the client to describe what happened last night
- C. Explain that the night nurse was probably busy
- D. Reassure the client that things will be better today
Correct Answer: B
Rationale: Asking for details (B) allows the charge nurse to understand the client’s concerns and address specific issues. Apologizing (A) assumes fault, excusing the nurse (C) dismisses the concern, and reassurance (D) lacks follow-through without investigation.
Intake and output record
Time Oral intake Parenteral intake Other intake Output
0700 150 mL vancomycin IV
0900 240 mL coffee 1500 mL dialysate
1100 120 mL tea
1300 100 mL cefepime IV 1400 mL dialysate outflow
1500 180 mL juice
The nurse is completing a client's intake and output record for the shift. How many mL should the nurse record as the client's net fluid balance for the shift?
Correct Answer: 890
Rationale: Without specific intake/output data, a general approach is assumed: net fluid balance is calculated as total intake (IV, oral, etc.) minus total output (urine, emesis, etc.). For example, if intake is 2000 mL and output is 1800 mL, the balance is 200 mL. The nurse must sum all recorded values accurately.