Nokea
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.
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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.
The nurse in the emergency department (ED) is assessing a client involved in a motor vehicle crash who sustained a penetrating abdominal trauma. The client’s vital signs are: T 97.5°F (36.4°C); P 108 bpm; RR 22; BP 98/64 mm Hg; pulse oximetry 94% on room air. Which of the following actions should the nurse take first?
- A. Prepare the client for surgery.
- B. Insert a nasogastric (NG) tube.
- C. Auscultate the client’s bowel sounds.
- D. Reassess vital signs.
Correct Answer: D
Rationale: Reassessing vital signs (D) is the first action to confirm stability or deterioration in a client with penetrating abdominal trauma and tachycardia/hypotension, guiding further interventions. Surgery prep (A), NG tube (B), and bowel sounds (C) follow reassessment.
The nurse is caring for a client who has developed compartment syndrome of their left lower extremity. After calling a rapid response following the nurse's assessment and receiving an order for emergency surgery, what priority action should the nurse take?
- A. Perform medication reconciliation.
- B. Reassess vital signs.
- C. Provide an update to the client's family.
- D. Transport the client to the operating room.
Correct Answer: D
Rationale: Transporting to the operating room (D) is the priority for compartment syndrome requiring emergency surgery to prevent tissue necrosis. Medication reconciliation (A), reassessing vitals (B), and family updates (C) delay time-sensitive intervention.
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.
The nurse is reviewing laboratory data for assigned clients. Which laboratory result requires immediate follow-up with the primary healthcare provider (PHCP)?
- A. Elevated amylase result in a client diagnosed with acute pancreatitis
- B. Elevated white blood cell (WBC) count in a client with an infected leg wound.
- C. Urinalysis positive for leukocytes and nitrites for a client receiving chemotherapy
- D. Serum glucose of 235 mg/dL (13.05 mmol/L) [70-110 mg/dL; 4-6 mmol/L] in a client with diabetes mellitus (type one)
Correct Answer: C
Rationale: Leukocytes and nitrites in urinalysis for a chemotherapy client (C) indicate a possible urinary tract infection, critical due to immunosuppression. Elevated amylase (A) and WBC (B) are expected, and glucose of 235 (D) is elevated but less urgent.