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The nurse has been made aware of the following client situations. The nurse should initially follow up with the client who
- A. had an adrenalectomy 24 hours ago and has become restless with the most recent blood pressure (BP) of 98/60 mm Hg.
- B. has a continuous infusion of heparin for the treatment of a pulmonary embolism (PE) and has an activated partial thromboplastin time (aPTT) of 70 seconds (normal 30-40 seconds).
- C. is receiving mechanical ventilation to treat hospital-acquired pneumonia (HAP) and was last suctioned via the endotracheal (ET) tube two hours ago.
- D. has a newly placed chest tube for hemothorax and has had 45 mL of bright red drainage in the past hour.
Correct Answer: A
Rationale: Restlessness and BP of 98/60 mm Hg 24 hours post-adrenalectomy (A) suggest possible adrenal crisis or hypovolemia, a life-threatening emergency requiring immediate follow-up. Elevated aPTT on heparin (B) indicates therapeutic anticoagulation, recent suctioning (C) is routine, and 45 mL chest tube drainage (D) is within normal limits, all less urgent.
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The nurse is caring for assigned clients. The nurse should initially follow-up on the client who
- A. has a blood glucose of 250 mg/dL (13.875 mmol/L) while being treated with prednisone for pneumonia.
- B. is receiving a continuous infusion of heparin and has a 50% reduction in platelets over the past five days.
- C. has diabetes mellitus (type two) and reports burning and tingling in both feet.
- D. is being treated for acute post-streptococcal glomerulonephritis and has an hourly urinary output of 20 ml/hr.
Correct Answer: B
Rationale: A 50% platelet drop on heparin (B) suggests heparin-induced thrombocytopenia, a life-threatening condition requiring immediate cessation of heparin. Hyperglycemia (A), neuropathy (C), and low urine output (D) are concerning but less acute, as they are expected or manageable with less urgency.
The nurse is observing unlicensed assistive personnel (UAP) care for assigned clients. Which of the following actions by the UAP would require the nurse to intervene? Select all that apply.
- A. While helping the client with an active range of motion, the UAP flexes and extends the client's elbow.
- B. Obtains orthostatic blood pressure by having the client stand first.
- C. Places the cane on the unaffected side of a client who had a stroke.
- D. Provides a hot foot soak for a client with diabetes mellitus.
- E. Obtains a urine culture from an indwelling urinary catheter.
Correct Answer: B, D, E
Rationale: Standing first for orthostatic BP (B) risks syncope, hot foot soaks for diabetes (D) risk burns due to neuropathy, and urine culture collection (E) requires sterile technique, all inappropriate for UAPs. Range of motion (A) and cane placement (C) are correct UAP tasks.
The nurse in the emergency department is triaging a group of clients. It would be a priority for the nurse to follow up with the child
- A. reporting increased urinary frequency and pain during urination.
- B. diagnosed with leukemia who has petechiae on their torso.
- C. diagnosed with acute epiglottitis two days ago and is drooling.
- D. with otitis media who has a temperature of 101.1°F (38.4°C) and is crying.
Correct Answer: C
Rationale: Drooling in a child with acute epiglottitis (C) suggests airway obstruction, a life-threatening emergency requiring immediate follow-up. Urinary symptoms (A), petechiae in leukemia (B), and otitis media (D) are less urgent, though concerning.
The nurse is performing an assessment on a client with pneumonia. The nurse should prioritize assessing the client's
- A. temperature.
- B. oral intake.
- C. lung sounds.
- D. white blood cell count.
Correct Answer: C
Rationale: Lung sounds (C) are the priority in pneumonia to assess for consolidation or respiratory compromise, guiding immediate interventions. Temperature (A), intake (B), and WBC count (D) are important but secondary, as they inform longer-term management.
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.