Nokea
The emergency department (ED) nurse is caring for a client admitted with septic shock. After administering prescribed intravenous fluids (IVF), which laboratory test does the nurse anticipate the physician will order to evaluate the IVF's efficacy?
- A. serum troponin
- B. serum glucose
- C. serum white blood cells
- D. serum lactic acid
Correct Answer: D
Rationale: Serum lactic acid is used to assess tissue perfusion and the effectiveness of fluid resuscitation in septic shock.
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The nurse is evaluating a client three days post-operative for signs and symptoms of infection. Which of the following is not a sign of infection from a surgical wound?
- A. Pus and clear drainage from the site
- B. Some redness along the edges of the site
- C. Increasing warmth from the wound
- D. Red streaks from the site
Correct Answer: B
Rationale: Some redness along the edges of a surgical wound is a normal part of the healing process, whereas pus, increasing warmth, and red streaks indicate infection.
The nurse has instructed a client newly diagnosed with the human immunodeficiency virus (HIV). Which of the following statements by the client would indicate effective understanding? This disease is caused by a retrovirus leading to?
- A. encapsulation of CD4+ T-cells.
- B. inflammation of the CD4+ T-cells.
- C. abnormal proliferation of CD4+ T-cells.
- D. viral integration into the CD4+ T-cells.
Correct Answer: D
Rationale: HIV, a retrovirus, integrates its genetic material into CD4+ T-cells, leading to immune dysfunction.
The following scenario applies to the next 1 items
The nurse in the emergency department is caring for a 19-year-old male client.
Item 1 of 1
Nurses' Note
Vital Signs
Client reports right elbow pain and swelling for three days. The client says that he scraped his elbow while rollerblading, and it has become painful and swollen for the past two days. He reports waking up with a fever of 101.3°F (38.5°C) and feeling lightheaded. On assessment, the client appeared lethargic and pale. The client has a full range of motion in the elbow but reports pain with movement. The client reports pain of '7' on a scale from 0-10. The elbow has erythema with a large red bump, swollen and hot to the touch. Clear lung fields bilaterally. S1/S2 heart tones. Normoactive bowel sounds. Denies nausea. History of asthma and seasonal
Allergies.
The nurse reports the assessment findings and vital signs to the primary healthcare provider (PHCP). Click to specify if the potential prescription is anticipated or contraindicated for this client.
- A. Obtain peripheral vascular access
- B. Administer albuterol via nebulizer
- C. Collect blood cultures
- D. Infuse hypertonic saline at 30 mL/kg
- E. Administer broad-spectrum antibiotics
- F. Collect serum lactic acid
Correct Answer: A: Anticipated, B: Contraindicated, C: Anticipated, D: Contraindicated, E: Anticipated, F: Anticipated
Rationale: A: Peripheral access is needed for diagnostics and treatment. B: Albuterol is not indicated without respiratory symptoms. C: Blood cultures identify the infection source. D: Hypertonic saline is inappropriate for this case. E: Broad-spectrum antibiotics treat suspected infection. F: Serum lactic acid assesses for sepsis.
The nurse in the emergency department (ED) is triaging a client who reports recent international travel to West Africa and has signs and symptoms of conjunctival injection, fever, rash, vomiting, and blood in their stool. The nurse is concerned that this client may have?
- A. pulmonary tuberculosis.
- B. encephalitis.
- C. Ebola virus disease.
- D. inhalation anthrax.
Correct Answer: C
Rationale: Ebola virus disease is associated with recent travel to West Africa and symptoms like fever, rash, vomiting, and hemorrhagic signs such as bloody stools.
Which of the following clients, receiving normal saline via IV infusion, is at the highest risk for bloodstream infections?
- A. A client who has a midline IV catheter in the left antecubital fossa.
- B. A client with a peripherally inserted central catheter (PICC) line in the right upper arm.
- C. A client with an implanted port in the right subclavian vein.
- D. A client who has a non-tunneled central line in the left internal jugular vein.
Correct Answer: D
Rationale: Non-tunneled central lines, such as those in the internal jugular vein, carry the highest risk of bloodstream infections due to their direct access to central circulation and external exposure.