Nokea
The nurse is caring for a client diagnosed with septic shock. Which assessment data warrant immediate intervention by the nurse?
- A. Vital signs T 100.4°F, P 104, R 26, and BP 102/60.
- B. A white blood cell count of 18,000/mm3.
- C. A urinary output of 90 mL in the last four (4) hours.
- D. The client complains of being thirsty.
Correct Answer: C
Rationale: Urinary output of 90 mL/4 hours = 22.5 mL/hour, below 30 mL/hour, indicating renal hypoperfusion, requiring immediate intervention. Fever, tachycardia, and elevated WBC are expected; thirst is less urgent.
You may also like to solve these questions
The ED nurse is caring for a female client with a greenstick fracture of the left forearm and multiple contusions on the face, arms, trunk, and legs. The significant other is in the treatment area with the client. Which nursing interventions should the nurse implement? List in order of priority.
- A. Determine if the client has a plan for safety.
- B. Assess the pulse, temperature, and capillary refill of the left wrist and hand.
- C. Ask the client if she feels safe in her own home.
- D. Request the significant other wait in the waiting room during the examination.
- E. Notify the social worker to consult on the case.
Correct Answer: D,C,A,B,E
Rationale: 1) Request significant other to wait (ensures private assessment); 2) Ask about safety (screens for abuse); 3) Plan for safety (addresses immediate risk); 4) Assess limb (ensures circulation); 5) Notify social worker (coordinates support).
The nurse is assessing the client who suffered a near-drowning event. Which data require immediate intervention?
- A. The onset of pink, frothy sputum.
- B. An oral temperature of 97°F.
- C. An alcohol level of 100 mg/dL.
- D. A heart rate of 100 beats/min.
Correct Answer: A
Rationale: Pink, frothy sputum indicates pulmonary edema, a life-threatening complication requiring immediate intervention. Normal temperature, alcohol levels, and tachycardia are less urgent.
The CPR instructor is discussing an automated external defibrillator (AED) during class. Which statement best describes an AED?
- A. It analyzes the rhythm and shocks the client in ventricular fibrillation.
- B. The client will be able to have synchronized cardioversion with the AED.
- C. It will keep the health-care provider informed of the client’s oxygen level.
- D. The AED will perform cardiac compressions on the client.
Correct Answer: A
Rationale: An AED analyzes rhythms and delivers shocks for ventricular fibrillation or pulseless ventricular tachycardia. Cardioversion, oxygen monitoring, and compressions are not AED functions.
The nurse is teaching the client home care instructions for a reimplanted finger after a traumatic amputation. Which information should the nurse include in the teaching?
- A. Perform range-of-motion exercises weekly.
- B. Smoking may be resumed if it does not cause nausea.
- C. Protect the finger and be careful not to reinjure the finger.
- D. An elevated temperature is the only reason to call the HCP.
Correct Answer: C
Rationale: Protecting the reimplanted finger prevents reinjury, critical for healing. ROM timing varies, smoking impairs circulation, and multiple symptoms warrant HCP contact.
The nurse finds the client unresponsive on the floor of the bathroom. Which action should the nurse implement first?
- A. Check the client for breathing.
- B. Assess the carotid artery for a pulse.
- C. Shake the client and shout.
- D. Notify the rapid response team.
Correct Answer: C
Rationale: Shaking and shouting assesses responsiveness per ACLS guidelines, the first step in a code. Breathing and pulse checks follow, and team notification is subsequent.