The client diagnosed with septicemia is receiving a broad-sp...

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 nurse and an unlicensed assistive personnel (UAP) are caring for a group of clients on a medical floor. Which action by the UAP warrants intervention by the nurse?

A. The UAP places a urine specimen in a biohazard bag in the hallway.
B. The UAP uses the alcohol foam hand cleanser after removing gloves.
C. The UAP puts soiled linen in a plastic bag in the client’s room.
D. The UAP obtains a disposable stethoscope for a client in an isolation room.

Correct Answer: A

Rationale: Urine specimens are not biohazardous unless visibly bloody; placing in a biohazard bag is incorrect and requires intervention. Hand cleansing, linen handling, and stethoscope use are appropriate.

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 intervention is most important for the nurse to implement when participating in a code?

A. Elevate the arm after administering medication.
B. Maintain sterile technique throughout the code.
C. Treat the client’s signs/symptoms; do not treat the monitor.
D. Provide accurate documentation of what happened during the code.

Correct Answer: C

Rationale: Treating the client’s clinical presentation (not just monitor readings) ensures appropriate care. Arm elevation, sterile technique, and documentation are secondary during active resuscitation.

The client with a temperature of 94°F is being treated in the ED. Which intervention should the nurse implement to directly elevate the client’s temperature?

A. Remove the client’s clothing.
B. Place a warm air blanket over the client.
C. Have the client change into a hospital gown.
D. Raise the temperature in the room.

Correct Answer: B

Rationale: A warm air blanket (e.g., Bair Hugger) directly raises core temperature in hypothermia. Removing clothing, changing gowns, or room temperature are less effective.