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The emergency department (ED) nurse cares for a client with diabetes mellitus (type one) with diabetic ketoacidosis (DKA). Which assessment finding requires immediate follow-up?
- A. Pulse 112/minute
- B. Nausea and vomiting
- C. Respiratory rate 21/minute
- D. Blood glucose 299 mg/dL (16.5 mmol/L) [70-110 mg/dL (4-6 mmol/L)]
Correct Answer: B
Rationale: Nausea and vomiting in DKA (B) can worsen dehydration and electrolyte imbalances, requiring immediate follow-up. Tachycardia (A) and tachypnea (C) are expected, and glucose of 299 (D) is consistent with DKA but less urgent.
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The nurse is triaging a client involved in a chemical spill at a local chemical plant. The nurse assesses the client as responsive but unable to walk, with a respiratory rate of 28 and capillary refill <2 seconds. It would be correct for the nurse to triage this client with a
- A. yellow tag.
- B. red tag.
- C. black tag.
- D. green tag.
Correct Answer: A
Rationale: A yellow tag (A) is appropriate for a responsive client unable to walk with stable vital signs (RR 28, capillary refill <2 sec), indicating urgent but not immediate life-threatening needs. Red (B) is for critical, black (C) for deceased, and green (D) for minor injuries.
A nurse is caring for a client who speaks a language different from the healthcare team. Which action by the nurse best ensures effective communication with the client?
- A. Using family members as interpreters.
- B. Utilizing a professional interpreter provided by the healthcare facility.
- C. Attempting to communicate using basic words and gestures.
- D. Referring the client to a language class for healthcare professionals.
Correct Answer: B
Rationale: A professional interpreter (B) ensures accurate, confidential communication, per Joint Commission standards. Family interpreters (A) risk bias, gestures (C) are unreliable, and language classes (D) are impractical for immediate needs.
The nurse has become aware of the following client situations. The nurse should first see the client who is receiving
- A. chemotherapy via a peripherally inserted central catheter (PICC) and reports blistering at the site.
- B. a chemotherapy infusion and develops nausea and vomiting.
- C. oral chemotherapy and reports burning in their mouth while drinking orange juice.
- D. external beam radiation therapy (EBRT) and sitting with visitors in the family waiting room.
Correct Answer: A
Rationale: Blistering at a PICC site during chemotherapy (A) suggests extravasation, a medical emergency requiring immediate intervention to prevent tissue damage. Nausea and vomiting (B) and oral burning (C) are less urgent side effects. Sitting with visitors (D) is a normal activity and not concerning.
The charge nurse is planning client care assignments for a registered nurse (RN) and licensed practical/vocational nurse (LPN/VN). Which of the following clients would be most appropriate to assign to the LPN?
- A. A client requiring assistance picking out low potassium foods.
- B. A client requesting to leave the facility against medical advice (AMA).
- C. A client needing several prescriptions called into the local pharmacy.
- D. A client requesting breakthrough intravenous push (IV) pain medicine.
Correct Answer: A
Rationale: Assisting with low potassium food choices (A) is within the LPN’s scope, involving reinforcement of dietary teaching. AMA requests (B) and IV pain medication (D) require RN judgment, and calling prescriptions (C) may involve complex coordination.
The nurse in the emergency department (ED) is caring for a client who intentionally overdosed on their prescribed lithium. The nurse plans on initially
- A. developing a therapeutic rapport with the client.
- B. inserting a peripheral vascular access device.
- C. obtaining the client’s vital signs.
- D. collecting a serum lithium level on the client.
Correct Answer: B
Rationale: Inserting a peripheral vascular access device (B) is the initial priority in a lithium overdose to enable rapid administration of fluids or medications to stabilize the client. Vital signs (C) and lithium levels (D) follow, and rapport (A) is secondary to medical stabilization.