Nokea
The nurse answers a call to the unit, which turns out to be a bomb threat. Which actions by the nurse are correct? Select all that apply.
- A. dismiss the call as a prank
- B. follow facility protocol to ensure client and staff safety
- C. try to find out where the bomb is and when it will go off
- D. alert the charge nurse, security, and the police department
- E. start evacuating clients, starting with those who are most mobile first
Correct Answer: B, D
Rationale: Following protocol and alerting authorities ensure safety and proper response, while dismissing the threat or evacuating without orders is unsafe.
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The nurse is caring for a client on airborne precautions. Which of the following would the nurse expect to see in the client's medical record?
- A. measles
- B. influenza
- C. Lyme disease
- D. herpes simplex
Correct Answer: A
Rationale: Measles requires airborne precautions due to its highly contagious nature via respiratory droplets, unlike the other conditions listed.
A pediatric nurse volunteers at a health screening fair. The nurse examines a patient. Which of the following findings may be indicative of type 1 diabetes and require further investigation?
- A. stomach bloating, swollen lymph nodes, increased thirst
- B. sudden weight loss, blurry vision, muscle weakness
- C. sudden weight gain, ringing in the ears, difficulty sleeping
- D. feeling hungry all of the time, increased thirst, waking up at night to urinate
Correct Answer: D
Rationale: Type 1 diabetes presents with polyphagia, polydipsia, and polyuria (e.g., waking to urinate). Weight loss (B) is also common, but D is the most specific.
Which laboratory finding would indicate a 62-year-old male client is at risk for ventricular dysrhythmia?
- A. magnesium 0.8 mmEq/L
- B. potassium 4.2 mmol/L
- C. creatinine 1.3 mg/dL
- D. total calcium 2.8 mmol/L
Correct Answer: A
Rationale: Low magnesium (0.8 mEq/L; normal 1.5-2.5 mEq/L) increases the risk of ventricular dysrhythmias. Other values are within normal ranges.
The client with a history of diabetes insipidus is admitted with polyuria, polydipsia, and mental confusion. The priority intervention for this client is:
- A. Measure the urinary output
- B. Check the vital signs
- C. Encourage increased fluid intake
- D. Weigh the client
Correct Answer: B
Rationale: Mental confusion in diabetes insipidus may indicate severe dehydration or electrolyte imbalance, so checking vital signs is the priority to assess stability.
A 22-year-old pregnant client is diagnosed with autoimmune hemolytic anemia. The nurse anticipates immediate treatment with
- A. IgA.
- B. IgG.
- C. IgE.
- D. IgD.
- E. None
Correct Answer: E
Rationale: Autoimmune hemolytic anemia in pregnancy is typically treated with corticosteroids or IVIG (containing IgG), but IgG alone isn’t administered. None of the options are correct.