Nokea
Laboratory reference ranges
Glucose (fasting)
70–110 mg/dL
(3.9–6.1 mmol/L)
The nurse is caring for a client who has acute pancreatitis. Which of the following findings is most concerning?
- A. Serum glucose levels for the past 24 hours are ≥250 mg/dL (13.9 mmol/L)
- B. Client is lying with knees drawn up to the abdomen to alleviate pain
- C. Temperature is 102.2°F (39°C) with increasing abdominal pain
- D. Five large, liquid stools are yellow and foul-smelling
Correct Answer: C
Rationale: Fever (102.2°F) with increasing abdominal pain suggests infection or abscess, a life-threatening complication of pancreatitis. Hyperglycemia, knee-flexed positioning, and diarrhea are concerning but less urgent.
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The nurse is reinforcing teaching with a client who has a prescription for sertraline for the treatment of depression. Which of the following statements by the client would indicate a correct understanding of the teaching?
- A. I can discontinue the medication as soon as I start feeling better
- B. I should avoid eating aged cheeses, cured meats, or pickled foods
- C. I should expect to feel better within 2 to 3 days after starting this medication
- D. I will report any thoughts of self-harm to my health care provider
Correct Answer: D
Rationale: Reporting self-harm thoughts is critical, as sertraline may increase suicide risk initially. Discontinuing abruptly risks relapse, food restrictions apply to MAOIs, and benefits take weeks, not days.
A nurse caring for a client with a central venous catheter (CVC) enters the client’s room and notes that the CVC is dislodged and lying in the client’s bed linens. The client appears cyanotic and is tachypneic and diaphoretic. Which of the following actions by the nurse are appropriate? Select all that apply.
- A. Administer oxygen via non-rebreather mask
- B. Apply an occlusive dressing over the insertion site
- C. Assist the client to high Fowler position
- D. Monitor vital signs and respiratory effort
- E. Notify the health care provider
Correct Answer: A,B,D,E
Rationale: Oxygen, occlusive dressing, vital sign monitoring, and provider notification address air embolism risk and hypoxia. High Fowler may worsen air entry; semi-Fowler is preferred.
A client newly returned to the unit after knee surgery asks the nurse for assistance to a chair. What action should the nurse implement first?
- A. Ask another nurse to help
- B. Delegate the task to unlicensed assistive personnel
- C. Premedicate the client for pain
- D. Verify the client's activity prescription
Correct Answer: D
Rationale: Verifying the activity prescription ensures the client is cleared for chair transfer, preventing injury. Assistance, delegation, or premedication are secondary until safety is confirmed.
The nurse is preparing the sterile field and supplies for a wet-to-damp dressing change. Which of the following actions by the nurse would require follow-up?
- A. Drop sterile gauze on the sterile field from 6 inches (15cm ) above
- B. Keeps the sterile field and sterile gloved hands within view at all times
- C. Places sterile gauze 2 inches (5 cm) inside the outer edge of the sterile drape
- D. Pours sterile saline solution from a recapped bottle opened 30 hours ago
Correct Answer: D
Rationale: Using saline from a bottle opened 30 hours ago risks contamination, as sterile solutions are typically discarded after 24 hours. Keeping the field in view and placing gauze appropriately maintain sterility.
While caring for a client in skeletal traction, which tasks can the nurse assign to experienced unlicensed assistive personnel to help prevent immobility hazards? Select all that apply.
- A. Assist with active and passive range of motion exercises
- B. Change bed linens while logrolling the client from side to side
- C. Check the color and temperature of the affected extremity
- D. Reapply pneumatic compression device after bathing the client
- E. Remind the client to use the incentive spirometer
Correct Answer: A,D,E
Rationale: Assisting with range of motion, reapplying compression devices, and reminding about spirometry are within UAP scope and prevent immobility issues. Assessing extremities and logrolling require nursing judgment.