Nokea
The nurse in the emergency department (ED) is caring for a client experiencing septic shock. The nurse should prioritize
- A. obtaining an order to insert an indwelling urethral catheter.
- B. monitoring the client's serum white blood cell count and lactic acid.
- C. establishing frequent blood pressure monitoring.
- D. monitoring the client's capillary blood glucose.
Correct Answer: C
Rationale: Frequent BP monitoring (C) is the priority in septic shock to assess hemodynamic stability and guide fluid/vasopressor therapy, per Surviving Sepsis guidelines. Catheter insertion (A), lab monitoring (B), and glucose checks (D) are secondary to immediate circulatory assessment.
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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.
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 in the family clinic is checking the vital signs of clients. Which client should the nurse prioritize?
- A. A 9-month-old baby with a pulse rate of 148
- B. A 2-year-old with a respiratory rate of 30
- C. A 24-week pregnant woman with a blood pressure of 148/96 mmHg
- D. A 40-year-old man with a temperature of 37.8°C (100.04°F)
Correct Answer: C
Rationale: A blood pressure of 148/96 mmHg in a 24-week pregnant woman (C) suggests preeclampsia, a priority for immediate assessment. A pulse of 148 (A) and respiratory rate of 30 (B) are normal for infants and toddlers, and a mild temperature (D) is less urgent.
The charge nurse is orientating a newly hired nurse to the charge nurse role. Which observation by the charge nurse requires follow-up? The newly hired nurse Select all that apply.
- A. requests the unlicensed assistive personnel (UAP) transport a client with respiratory distress to radiology.
- B. asks the licensed practical/vocational nurse (LPN/VN) to witness informed consent for a client scheduled for surgery.
- C. instructs the licensed practical/vocational nurse (LPN/VN) to review orders just written by the physician.
- D. assks the unlicensed assistive personnel (UAP) to transport blood specimens to the lab.
- E. assigns a client immediately postoperative from cardiac catheterization to a licensed practical/vocational nurse (LPN/VN).
Correct Answer: A, B
Rationale: Transporting a client with respiratory distress (A) by a UAP is unsafe, as they require monitoring. An LPN witnessing consent (B) is outside their scope; RNs or providers typically do this. Reviewing orders (C), transporting specimens (D), and assigning a stable post-catheterization client (E) are appropriate.
The nurse is caring for assigned clients. The nurse should initially assess the client who
- A. is recovering from a femoral angioplasty and reports their foot is falling asleep.
- B. has diabetes mellitus and refused their prescribed glargine insulin.
- C. received alteplase three hours ago for a stroke and has a Glasgow Coma Scale of 14.
- D. had a T6 spinal cord injury and has not had a bowel movement since yesterday.
Correct Answer: A
Rationale: Numbness post-femoral angioplasty (A) suggests vascular compromise, such as occlusion, requiring immediate assessment. Insulin refusal (B), stable GCS post-alteplase (C), and constipation in spinal injury (D) are less urgent.