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The nurse is caring for a client with diabetic ketoacidosis and is prescribed a bolus of regular insulin followed by a continuous infusion of regular insulin. Prior to starting the continuous infusion, the nurse administers 1 unit/kg of regular insulin to the client instead of the 0.1 unit/kg bolus. The nurse should take which initial action?
- A. Notify the primary healthcare provider (PHCP)
- B. Complete an incident report
- C. Assess the client for hypoglycemia
- D. Withhold the insulin infusion
Correct Answer: C
Rationale: Administering a 10-fold insulin overdose (C) risks severe hypoglycemia, so assessing the client immediately is critical to detect and treat low glucose. Notifying the PHCP (A), reporting (B), and withholding infusion (D) follow but are less urgent than client assessment.
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The nurse is delegating tasks to an unlicensed assistive personnel (UAP). Which of the following activities would be appropriate to delegate? Select all that apply.
- A. Performing initial client assessments
- B. Making client beds
- C. Giving clients bed baths
- D. Administering client medications
- E. Ambulating clients
- F. Assisting clients with meals
Correct Answer: B, C, E, F
Rationale: UAPs can make beds (B), give bed baths (C), ambulate clients (E), and assist with meals (F), as these are non-clinical tasks. Initial assessments (A) and medication administration (D) require nursing judgment, reserved for RNs or LPNs.
The Unlicensed Assistive Personnel (UAP) is helping a female patient with early ambulation postsurgery. The CNA has just applied a gait belt to the patient's waist. Which of the following actions by the CNA will need interference and correction by the supervising nurse?
- A. Holding onto the belt's outer edge or center, preventing the patient from leaning or drooping to one side.
- B. Pulling from the front of the belt, keeping forward momentum.
- C. Bringing the client to a nearby chair when she feels dizzy.
- D. Keeping the patient's body weight close to her own.
Correct Answer: B
Rationale: Pulling from the front of the gait belt (B) risks causing the client to lose balance or fall, requiring correction. Holding the belt (A), seating a dizzy client (C), and maintaining close body alignment (D) are appropriate and safe actions.
The nurse is caring for a client who has developed compartment syndrome of their left lower extremity. After calling a rapid response following the nurse's assessment and receiving an order for emergency surgery, what priority action should the nurse take?
- A. Perform medication reconciliation.
- B. Reassess vital signs.
- C. Provide an update to the client's family.
- D. Transport the client to the operating room.
Correct Answer: D
Rationale: Transporting to the operating room (D) is the priority for compartment syndrome requiring emergency surgery to prevent tissue necrosis. Medication reconciliation (A), reassessing vitals (B), and family updates (C) delay time-sensitive intervention.
The nurse is caring for a client who has just returned from receiving a hemodialysis treatment. It would require immediate follow-up by the nurse if the client has
- A. a temperature (T) of 99.4°F (37.4°C).
- B. restlessness and a headache.
- C. weight loss of 3 kilograms (6.6 pounds).
- D. persistent fatigue.
Correct Answer: B
Rationale: Restlessness and headache post-hemodialysis (B) suggest disequilibrium syndrome or hypotension, critical complications requiring immediate follow-up. Mild fever (A), weight loss (C), and fatigue (D) are expected or less urgent.
When experiencing conflict with another nurse (that is not resolvable between the parties), what is the most appropriate action for the nurse moving forward?
- A. Report the conflict to the director of nursing over the unit.
- B. Report the conflict to the nurse manager of the unit.
- C. Report the conflict to the assigned charge nurse of the unit.
- D. Discuss the conflict with another nurse to attempt resolution of the issue.
Correct Answer: B
Rationale: Reporting to the nurse manager (B) follows the chain of command for unresolved conflict, ensuring appropriate resolution. The director (A) is too high, the charge nurse (C) may lack authority, and discussing with another nurse (D) risks gossip and unprofessionalism.