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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The registered nurse (RN) is orienting a new RN to the charge nurse role. When delegating tasks, which task delegated to the licensed practical/vocational nurse (LPN/VN) would require follow-up from the charge nurse?
- A. Obtaining an occult stool sample for a client with ulcerative colitis.
- B. Assessing a newly admitted client with chest pain.
- C. Reinforcing teaching to a client newly diagnosed with diabetes mellitus.
- D. Providing pin care for a client with external fixation of the wrist.
Correct Answer: B
Rationale: Assessing a new client with chest pain (B) requires RN-level judgment due to potential life-threatening conditions, necessitating follow-up if delegated to an LPN. Stool sample collection (A), reinforcing teaching (C), and pin care (D) are within LPN scope.
The nurse in the emergency department (ED) is reviewing triage data for assigned clients. The nurse should initially follow up on the client who
- A. is requesting screening for pulmonary tuberculosis after traveling domestically in the United States.
- B. is being treated for a diabetic foot ulcer and requires a dressing change.
- C. is pregnant and has a fever accompanied by a generalized vesicular rash.
- D. is concerned they may have acquired human immunodeficiency virus (HIV) following unprotected sexual activity.
Correct Answer: C
Rationale: A pregnant client with fever and vesicular rash (C) suggests possible varicella or herpes, posing risks to mother and fetus, requiring immediate follow-up. TB screening (A), foot ulcer dressing (B), and HIV concern (D) are less urgent, as they are preventive or chronic.
The nurse is caring for a client with congestive heart failure. Using the ISBAR format, Select the text that expresses the nurses' recommendation to the physician.
- A. Client reported a cough and shortness of breath while resting.
- B. The onset of symptoms was sudden and not relieved, with the client being positioned with the head of the bed at 90 degrees.
- C. Vital signs were obtained: 156/98; P 108; RR 26/minute; Oxygen saturation 91% on room air.
- D. Lung sounds had crackles in all fields.
- E. A rapid response was called because of the unstable vital signs.
- F. Dr. Thomas Smith was notified to obtain diuretics and critical care monitoring orders.
Correct Answer: B,F
Rationale: Notifying Dr. Smith for diuretics and critical care monitoring (F) is the recommendation in the ISBAR format, proposing specific actions for the physician to address the client’s worsening heart failure. Other options provide situation (A, B), background (C, D), or assessment (E) details.
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 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.