Nokea
The nurse has received the following prescriptions for newly admitted clients. The nurse should first administer which of the following?
- A. Enoxaparin to a client with a platelet count of 165,000 mm3 (165 × 10^9/L) [150-400 mm3, 130-380 × 10^9/L]
- B. Warfarin to a client with an international normalized ratio of 2.4 [0.9-1.2 seconds]
- C. Packed red blood cells to a client with a hemoglobin of 6.1 g/dL (3.78 mmol/L) [Female: 12-16 g/dL, Male: 14-18 g/dL, Female 115-155 g/L, Male 125-170 g/L]
- D. Regular insulin to a client with a blood glucose of 285 mg/dL (15.77 mmol/L) [70-110 mg/dL, 4.0-11.0 mmol/L]
Correct Answer: C
Rationale: Packed red blood cells for hemoglobin of 6.1 g/dL (C) is the priority to address severe anemia, which can cause tissue hypoxia. Enoxaparin (A) is safe with normal platelets, warfarin (B) is therapeutic at INR 2.4, and insulin (D) is urgent but less critical than severe anemia.
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The nurse is triaging phone calls in the prenatal clinic. The nurse should initially follow-up on the client who is
- A. 16 weeks of gestation and reports a fluttering sensation.
- B. 30 weeks of gestation and reports perianal itching and bright red blood in the stool.
- C. 28 weeks of gestation and reports intermittent leg cramping with swelling in her feet.
- D. 38 weeks of gestation and reports lower back pain that increases with walking.
Correct Answer: B
Rationale: Bright red blood in the stool at 30 weeks gestation (B) suggests possible hemorrhoids, rectal fissure, or other complications, requiring urgent follow-up to rule out serious conditions. Fluttering at 16 weeks (A) is normal quickening, leg cramps and swelling at 28 weeks (C) are common, and back pain at 38 weeks (D) is typical, all less urgent.
The following scenario applies to the next 1 items
The charge nurse in the medical-surgical unit is preparing the assignment for the next shift.
• Client One
• 63-year-old male admitted three days ago for community-acquired pneumonia.
• Intravenous (IV) antibiotics stopped and were switched to oral. Plan is for discharge in one day. Family is at the bedside.
• Current medications: azithromycin, levofloxacin, warfarin, atorvastatin, acetaminophen, and albuterol via nebulizer.
• Medical history: mitral valve replacement, venous thromboembolism, and hyperlipidemia.
• Vital signs: T 101° F (39.7° C), P 72, RR 18, BP 130/86, pulse oximetry reading 95% on room air.
• Client Two
• 55-year-old female admitted two days ago with aplastic anemia.
• Received two units of packed red blood cells yesterday.
• Client is scheduled to receive two units of platelets. She developed epistaxis and vaginal bleeding in the last hour.
• Current medications: multivitamin and lisinopril.
• Medical history: aplastic anemia and hypertension.
• Vital signs: T 98.6° F (37° C), P 88, RR 15, BP 111/76, pulse oximetry reading 96% on room air.
• Client Three
• 23-year-old male admitted four days ago with chest trauma caused by a stab wound.
• Transferred to the medical-surgical unit yesterday. Chest tube was discontinued yesterday.
• Client is to ambulate every four hours (while awake). Has constipation and needs an enema.
• Current medications: oxycodone-acetaminophen, docusate, and regular insulin sliding scale.
• Medical history: diabetes mellitus (type one).
• Vital signs: T 98° F (36.4° C), P 80, RR 16, BP 119/86, pulse oximetry reading 96% on room air.
• Client Four
• 52-year-old female admitted two hours ago following total abdominal hysterectomy.
• Occasional nausea. Hypoactive bowel sounds in all quadrants. Has an indwelling urinary catheter connected to drainage bag.
• Current medications: hydrocodone-acetaminophen, docusate, and ondansetron.
• Medical history: cervical cancer.
• Vital signs: T 98° F (36.4° C), P 70, RR 16, BP 125/88, pulse oximetry reading 95% on room air
• Client Five
• 45-year-old male admitted four hours ago with new onset atrial fibrillation.
• Irregular pulse. Had two episodes of syncope in the emergency department.
• Current medications: continuous infusion of diltiazem.
• Medical history: hypertension and congestive heart failure.
• Vital signs: T 98° F (36.4° C), P 101, RR 19, BP 137/90, pulse oximetry reading 96% on room air
• Client Six
• 77-year-old male admitted one day ago with cystitis.
• Receives medications and feedings through percutaneous endoscopic gastrostomy (PEG). Requires daily dressing changes for sacral pressure ulcer.
• Current medications: citalopram, esomeprazole, atenolol, ciprofloxacin.
• Medical history: hypertension, anxiety, acid reflux.
• Vital signs: T 98.2° F (36.8° C), P 82, RR 15, BP 133/88, pulse oximetry reading 95% on room air
• Client Seven
• 72-year-old female admitted two days ago with cystitis and improving altered mental status.
• Receiving intermittent intravenous piggyback antibiotics.
• Current medications: rivaroxaban, diltiazem, and captopril.
• Medical history: atrial fibrillation and hypertension.
• Vital signs: T 98.9° F (37.2° C), P 67, RR 16, BP 143/85, pulse oximetry reading 96% on room air
The charge nurse is determining which client should be assigned to the licensed practical/vocational nurse (LPN/VN) or registered nurse (RN).Click to specify if the client should be assigned to the LPN/VN or RN.
- A. Client One
- B. Client Two
- C. Client Three
- D. Client Four
- E. Client Five
- F. Client Six
- G. Client Seven
Correct Answer:
Rationale: Client One
This client is stable, with IV antibiotics discontinued and switched to oral. The LPN can manage routine medication administration, monitor for any signs of infection recurrence, and provide discharge education under the supervision of an RN.
Client Three
The client is stable and primarily requires routine care, such as scheduled ambulation and assistance with bowel management (enema administration). The LPN is qualified to administer medications and monitor for any changes in respiratory status following chest trauma.
Client Six
This client is stable and requires PEG tube feedings, medication administration, and daily dressing changes for a sacral pressure ulcer. These tasks fall within the LPN’s scope of practice, as long as the RN remains available for more complex assessments if needed.
Client Seven
The client is showing improvement, is hemodynamically stable, and requires intermittent IV piggyback antibiotics. LPNs are trained to administer IV piggyback medications and monitor for adverse effects. Routine vital sign monitoring and medication administration are appropriate for LPN delegation.
Clients that should be assigned to the RN
Client Two
This client presents an increased risk of hemodynamic instability due to new-onset bleeding (epistaxis and vaginal bleeding), requiring close assessment and intervention. The RN is needed to evaluate the severity of bleeding, administer platelet transfusions, and monitor for transfusion reactions or worsening anemia.
Client Four
Postoperative clients are at risk for complications such as hemorrhage, infection, and ileus. The RN is required to perform a comprehensive assessment, evaluate bowel function, manage nausea, and ensure the catheter remains patent without signs of infection.
Client Five
This client is on continuous IV diltiazem, which requires ongoing cardiac monitoring and dosage adjustments based on response. The client’s history of syncope raises concerns for hemodynamic instability, which necessitates RN oversight for timely intervention if deterioration occurs.
The nurse performs a handoff report to the oncoming nurse for an older adult male in the intensive care unit (ICU). Which information is a priority to share with the oncoming nurse? The client
- A. has clear lung fields bilaterally with unlabored respirations.
- B. is forgetful and was not requesting assistance before getting out of bed.
- C. has a 20-gauge peripheral vascular access device that is patent and saline locked.
- D. has an indwelling urinary catheter that is patent with clear urine and is secured to the upper thigh.
Correct Answer: B
Rationale: Forgetfulness and not requesting help (B) indicate a high fall risk, a priority to share to ensure safety measures are in place. Clear lungs (A), patent IV (C), and urinary catheter (D) are stable and less urgent.
The emergency department (ED) nurse cares for a client who presents with irritability, nuchal rigidity, and a fever. Which of the following actions should the nurse take first?
- A. Administer prescribed ibuprofen.
- B. Place the client on droplet precautions.
- C. Notify the public health department.
- D. Obtain prescribed blood cultures.
Correct Answer: B
Rationale: Placing the client on droplet precautions (B) is the first action for suspected meningitis (irritability, nuchal rigidity, fever) to prevent spread of infection. Administering ibuprofen (A), notifying public health (C), and obtaining blood cultures (D) are important but secondary to infection control.
A 30-year old patient presents to the Emergency Department with alcohol withdrawal seizures. The psychiatry nurse understands that the patient will soon be admitted to the non-medical psychiatric care unit. To keep this patient safe, the nurse must perform which priority nursing action?
- A. Ask the physician for a clonazepam prescription, an anxiolytic that may help with the withdrawal symptoms.
- B. Ensure that a working IV pump is set up at the patient's bedside.
- C. Order a STAT arterial blood gas (ABG).
- D. Pad the side rails of the patient's assigned bed.
Correct Answer: D
Rationale: Padding the side rails (D) is the priority to prevent injury during ongoing or recurrent seizures in alcohol withdrawal, ensuring immediate safety. Requesting clonazepam (A) requires a physician order and is secondary, IV pump setup (B) is not urgent unless medication is ordered, and ABG (C) is unnecessary unless respiratory distress is present.