Nokea
The client diagnosed with septicemia is receiving a broad-spectrum antibiotic. Which laboratory data require the nurse to notify the health-care provider?
- A. The client’s potassium level is 3.8 mEq/L.
- B. The urine culture indicates high sensitivity to the antibiotic.
- C. The client’s pulse oximeter reading is 94%.
- D. The culture and sensitivity is resistant to the client’s antibiotic.
Correct Answer: D
Rationale: Antibiotic resistance requires immediate HCP notification to adjust therapy. Normal potassium, sensitive cultures, and 94% SpO2 are not urgent.
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The client in a code is now in ventricular bigeminy. The HCP orders a lidocaine drip at three (3) mg/min. The lidocaine comes prepackaged with two (2) grams of lidocaine in 500 mL of D5W. At which rate will the nurse set the infusion pump?
Correct Answer: 45
Rationale: Lidocaine concentration: 2 g = 2000 mg in 500 mL = 4 mg/mL. Dose: 3 mg/min. Rate = (3 mg/min) / (4 mg/mL) = 0.75 mL/min = 45 mL/hour (0.75 * 60). Pump set to 45 mL/hour.
The nurse is teaching a class on disaster preparedness. Which are components of an emergency operations plan (EOP)? Select all that apply.
- A. A plan for practice drills.
- B. A deactivation response.
- C. A plan for internal communication only.
- D. A preincident response.
- E. A security plan.
Correct Answer: A,B,D,E
Rationale: An EOP includes practice drills, deactivation, preincident planning, and security. Communication plans include external stakeholders, not just internal.
Which problem is most appropriate for the nurse to identify for the client experiencing renal trauma?
- A. Infection of the renal tract.
- B. Ineffective tissue perfusion.
- C. Alteration in skin integrity.
- D. Alteration in temperature.
Correct Answer: B
Rationale: Renal trauma risks bleeding and hypoperfusion, making ineffective tissue perfusion the primary problem. Infection, skin integrity, and temperature are less immediate.
Which question is an appropriate interview question for the nurse to use with clients involved in abuse?
- A. I know you are being abused. Can you tell me about it?
- B. How much does your spouse drink before he hits you?
- C. What did you do to cause your spouse to get mad?
- D. Do you have a plan if your partner becomes abusive?
Correct Answer: D
Rationale: Asking about a safety plan is non-judgmental and empowers the client. Accusatory, alcohol-focused, or blame-oriented questions hinder trust.
The client is diagnosed with neurogenic shock. Which signs/symptoms should the nurse assess in this client?
- A. Cool, moist skin.
- B. Bradycardia.
- C. Wheezing.
- D. Decreased bowel sounds.
Correct Answer: B
Rationale: Neurogenic shock causes bradycardia due to loss of sympathetic tone. Cool, moist skin is typical of hypovolemic shock, wheezing suggests anaphylaxis, and decreased bowel sounds are non-specific.