Nokea
The charge nurse reviews medical records for clients ready for discharge from the nursing unit. Which client should be recommended for disease management services? A client with
- A. congestive heart failure (CHF), who has been admitted three times in the past two months.
- B. epilepsy who had one seizure after switching prescribed antiepileptics.
- C. diabetes mellitus, with an increase in hemoglobin A1C from 6.7% to 6.9%.
- D. schizophrenia being switched from daily dosing to long-acting injectable antipsychotic.
Correct Answer: A
Rationale: Frequent CHF admissions (A) indicate poor disease control, making the client ideal for disease management services to prevent readmissions. Seizure after medication change (B), slight A1C increase (C), and schizophrenia medication switch (D) are less indicative of ongoing management needs.
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While caring for a client who requires a mechanical ventilator for breathing, the high-pressure alarm goes off on the ventilator. What is the first action the nurse should perform?
- A. Disconnect the client from the ventilator and use a manual resuscitation bag.
- B. Perform a quick assessment of the client's condition.
- C. Call the respiratory therapist for help.
- D. Press the alarm reset button on the ventilator.
Correct Answer: B
Rationale: A high-pressure alarm suggests obstruction or resistance, so assessing the client’s condition (B) first identifies the cause (e.g., tube kinking, secretions). Disconnecting (A), calling for help (C), or resetting (D) without assessment risks harm or delays resolution.
A medication error has occurred in the medical ward. After a thorough investigation was performed, the nurse manager posts a memorandum regarding changes in medication administration to be implemented immediately. The nurses on the unit recognized this management style as:
- A. Autocratic
- B. Democratic
- C. Participative
- D. Laissez-faire
Correct Answer: A
Rationale: Posting a memorandum with immediate changes (A) reflects an autocratic management style, where the manager makes decisions unilaterally. Democratic (B) and participative (C) involve staff input, while laissez-faire (D) lacks direction.
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 nurse has been made aware of the following client situations. The nurse should initially follow up with the client who
- A. had an adrenalectomy 24 hours ago and has become restless with the most recent blood pressure (BP) of 98/60 mm Hg.
- B. has a continuous infusion of heparin for the treatment of a pulmonary embolism (PE) and has an activated partial thromboplastin time (aPTT) of 70 seconds (normal 30-40 seconds).
- C. is receiving mechanical ventilation to treat hospital-acquired pneumonia (HAP) and was last suctioned via the endotracheal (ET) tube two hours ago.
- D. has a newly placed chest tube for hemothorax and has had 45 mL of bright red drainage in the past hour.
Correct Answer: A
Rationale: Restlessness and BP of 98/60 mm Hg 24 hours post-adrenalectomy (A) suggest possible adrenal crisis or hypovolemia, a life-threatening emergency requiring immediate follow-up. Elevated aPTT on heparin (B) indicates therapeutic anticoagulation, recent suctioning (C) is routine, and 45 mL chest tube drainage (D) is within normal limits, all less urgent.
The nurse is caring for a client taking prescribed captopril. Which abnormal laboratory value should the nurse prioritize when notifying the healthcare provider?
- A. Serum creatinine 1.3 mg/dL (114.92 μmol/L) [Male: 0.6-1.2 mg/dL, Female: 0.5-1.1 mg/dL, Male 49-93 μmol/L, Female 22-75 μmol/L]
- B. Serum potassium 5.2 mEq/L (mmol/L) [3.5-5 mEq/L (mmol/L)]
- C. Serum phosphorus 4.6 (1.48 mmol/L) [2.5-4.5 mg/dL, 0.81-1.58 mmol/L]
- D. Blood glucose 135 mg/dL (7.5 mmol/L) [70-110 mg/dL, 4-6 mmol/L]
Correct Answer: B
Rationale: Hyperkalemia (potassium 5.2 mEq/L, B) is a priority with captopril, an ACE inhibitor, as it can cause life-threatening arrhythmias. Creatinine (A) and phosphorus (C) are slightly elevated but less urgent. Glucose (D) is elevated but not critical in this context.