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The emergency department (ED) nurse is caring for a client admitted with diabetic ketoacidosis (DKA). Which clinical data requires immediate follow-up?
- A. Respiratory rate (RR) 23/minute
- B. Capillary blood glucose 319 mg/dL (17.70 mmol/L) [70-110 mg/dL, 4.0-11.0 mmol/L]
- C. Mean arterial pressure (MAP) 51 mm Hg
- D. PaO2 90 mm Hg [80-100 mm Hg]
Correct Answer: C
Rationale: A MAP of 51 mm Hg in DKA (C) indicates severe hypotension and organ hypoperfusion, requiring immediate fluid resuscitation. RR 23 (A) and glucose 319 (B) are expected in DKA, and PaO2 90 (D) is normal, none requiring immediate action.
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The nurse is caring for a group of clients in the emergency department. Which client situation requires immediate follow-up? A client
- A. transdermal nitroglycerin applied for angina and newly nits reports a headache.
- B. receiving intravenous fluids for diabetic ketoacidosis and has an outstanding order for a regular insulin infusion.
- C. receiving a continuous infusion of esmolol for an abdominal aortic aneurysm and reports flank pain.
- D. who just received discharge orders and needs teaching on how to care for their fractured radius.
Correct Answer: B,C
Rationale: An outstanding insulin infusion order for diabetic ketoacidosis (B, C) is critical to prevent life-threatening metabolic deterioration. Flank pain with esmolol infusion (A) suggests aneurysm expansion or rupture, also urgent, but insulin (D) is more immediately actionable. Nitrate headaches (A) are common and benign, and discharge teaching (B) is non-urgent.
The charge nurse is orientating a newly hired nurse to the charge nurse role. Which observation by the charge nurse requires follow-up? The newly hired nurse Select all that apply.
- A. requests the unlicensed assistive personnel (UAP) transport a client with respiratory distress to radiology.
- B. asks the licensed practical/vocational nurse (LPN/VN) to witness informed consent for a client scheduled for surgery.
- C. instructs the licensed practical/vocational nurse (LPN/VN) to review orders just written by the physician.
- D. assks the unlicensed assistive personnel (UAP) to transport blood specimens to the lab.
- E. assigns a client immediately postoperative from cardiac catheterization to a licensed practical/vocational nurse (LPN/VN).
Correct Answer: A, B
Rationale: Transporting a client with respiratory distress (A) by a UAP is unsafe, as they require monitoring. An LPN witnessing consent (B) is outside their scope; RNs or providers typically do this. Reviewing orders (C), transporting specimens (D), and assigning a stable post-catheterization client (E) are appropriate.
The nurse and unlicensed assistive personnel (UAP) are caring for assigned clients. Which of the following tasks should the nurse assign to the UAP?
- A. Obtain a tympanic temperature for a client who received naproxen one hour ago
- B. Record and empty a closed suction drain for a client recovering from a mastectomy
- C. Assist a client in picking out low-sodium foods on their lunch menu
- D. Transport a client receiving an infusion of dopamine to the intensive care unit
Correct Answer: A
Rationale: Obtaining a tympanic temperature (A) is a routine task within UAP scope. Recording drain output (B), dietary education (C), and transporting a client on dopamine (D) require nursing judgment or monitoring.
The nurse is caring for assigned clients. The nurse should first assess the client
- A. with a right femur fracture who reports pain rated as 4 on a scale of 0 (no pain) to 10 (severe pain).
- B. with chronic obstructive pulmonary disease (COPD) who is reporting shortness of breath while ambulating in the hallway.
- C. with a history of T6 spinal injury 6 months ago, now reports a severe headache and is diaphoretic.
- D. one day postoperative from an open cholecystectomy with green drainage from the t-tube.
Correct Answer: C
Rationale: Severe headache and diaphoresis in a T6 spinal injury (C) suggest autonomic dysreflexia, a life-threatening emergency. COPD shortness of breath (B), femur fracture pain (A), and t-tube drainage (D) are less urgent.
The nursing supervisor has implemented a new assignment system for nursing staff. In order to reduce resistance to this new system, the nurse manager should
- A. Provide incentives to foster the change
- B. Allow nursing staff to discuss potential concerns
- C. Provide statistical support for the change
- D. Detail the changes in a multimedia presentation
Correct Answer: B
Rationale: Allowing staff to discuss concerns (B) reduces resistance by fostering open communication and involvement, addressing potential barriers. Incentives (A), statistics (C), and presentations (D) are supportive but less effective without staff input.