Nokea
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.
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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.
The nurse is developing a staff in-service on negligence. A participant demonstrates correct understanding by identifying which elements must be met in a negligence lawsuit? Select all that apply.
- A. Duty owed
- B. Breach of duty owed
- C. Causation
- D. Harm or damages
- E. Beneficence
Correct Answer: A, B, C, D
Rationale: Negligence requires duty owed (A), breach of duty (B), causation (C), and harm or damages (D). Beneficence (E) is an ethical principle, not a legal element of negligence.
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 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.
A nurse observes a colleague failing to perform hand hygiene before entering multiple client rooms and administering medications. What is the most appropriate action by the nurse?
- A. Confront the colleague immediately in a client's room to stop the behavior
- B. Document the incident in the nurse's notes while monitoring for further issues
- C. Immediately report the behavior to the nurse manager for follow-up
- D. Assume the colleague is having a busy shift, and address it at a later time
Correct Answer: C
Rationale: Reporting to the nurse manager (C) ensures prompt follow-up on a serious infection control breach that risks client safety. Confronting in a client’s room (A) is unprofessional, documenting without action (B) delays intervention, and assuming busyness (D) ignores the safety violation.