Nokea
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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A patient in the prenatal clinic has stated her intention to choose formula feeding for her infant. Identify which action by the nurse is most appropriate in being a patient advocate.
- A. Remind the patient of why breast feeding is the best method of infant feeding.
- B. Request a referral to the lactation consultant.
- C. Determine the patient's knowledge base related to infant feeding options.
- D. Accept the patient's decision without further discussion.
Correct Answer: C
Rationale: Determining the patient’s knowledge base (C) respects her autonomy while ensuring informed decision-making, aligning with patient advocacy. Reminding about breastfeeding (A) or referring to a consultant (B) may pressure the patient, and accepting without discussion (D) neglects education.
The RN is the only RN in the assisted care facility on a busy evening shift. Of the following tasks, which ones can be safely delegated to an experienced LPN/LVN? Select all that apply.
- A. Completing an admission assessment on a new patient
- B. Administering routine oral medications to stable patients.
- C. Removal of a urinary catheter
- D. Completing a dressing change
- E. Administering an initial dose of a new medication to a patient.
Correct Answer: B, C, D
Rationale: Routine oral medications (B), urinary catheter removal (C), and dressing changes (D) are within an experienced LPN’s scope for stable patients. Admission assessments (A) and initial new medication doses (E) require RN judgment due to potential instability or adverse reactions.
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.
The nurse is caring for a child in the emergency department (ED) who sustained a bite from a rabid animal. The nurse should take which initial action
- A. Complete a detailed wound assessment
- B. Cleanse the wound with soap and water
- C. Obtain a prescription for an antibiotic
- D. Report the bite to animal control
Correct Answer: B
Rationale: Cleansing the wound with soap and water (B) is the initial action for a rabid animal bite to reduce viral load and infection risk, per CDC recommendations. Wound assessment (A), antibiotics (C), and reporting (D) follow initial cleaning.
The nurse in the emergency department (ED) is caring for a client and establishes continuous cardiac monitoring. Which initial action should the nurse take based on the electrocardiogram tracing? See the exhibit for additional client information.
- A. Establish vascular access and request a prescription for atropine
- B. Assess the client's blood pressure and level of consciousness
- C. Obtain and review the client's current medications
- D. Document the findings and reassess the client in one hour
Correct Answer: B
Rationale: Sinus bradycardia can be benign or symptomatic. The priority is to determine whether the client is hemodynamically stable by assessing blood pressure (BP) and level of consciousness (LOC). If the client is symptomatic (e.g., hypotension, dizziness, altered mental status), further interventions such as atropine administration may be required.