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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 caring for the following assigned clients. It would be a priority to follow up with a client who
- A. is being treated for acute glomerulonephritis (AGN) and has periorbital edema.
- B. has urolithiasis and reports persistent nausea.
- C. is receiving continuous bladder irrigation and reports the need to void.
- D. just returned from a hemodialysis session and reports dizziness.
Correct Answer: D
Rationale: Dizziness post-hemodialysis (D) suggests hypotension or fluid shifts, a life-threatening complication requiring immediate follow-up. Edema in AGN (A), nausea with urolithiasis (B), and voiding sensation with irrigation (C) are less urgent.
The registered nurse (RN) is planning client care assignments. Which client would be appropriate to assign to the licensed practical/vocational nurse (LPN/VN)? A client
- A. with Guillain-Barre syndrome client reporting dyspnea while at rest.
- B. with stage 3 and 4 pressure injuries present in the sacral area.
- C. 2 hours postoperative total laryngectomy.
- D. awaiting a referral for outpatient diabetic support services.
Correct Answer: D
Rationale: A client awaiting a referral for diabetic support services (D) is stable and suitable for LPN care, involving coordination within scope. Guillain-Barré syndrome with dyspnea (A), severe pressure injuries (B), and recent laryngectomy (C) require RN assessment due to critical or complex needs.
The nurse manager plans to develop a unit-based council to assist in decision-making. The nurse manager is demonstrating which leadership style?
- A. Authoritative
- B. Democratic
- C. C. Laissez-Faire
- D. D. Transactional
Correct Answer: B
Rationale: A unit-based council reflects a democratic leadership style (B), involving staff in decision-making. Authoritative (A) is directive, laissez-faire (C) is passive, and transactional (D) focuses on rewards and tasks, not shared governance.
After talking to a her family, an elderly client says that she wants to change their living will she wrote two weeks ago. The nurse's most appropriate reply would be:
- A. You can only change your living will a year after it is formulated.
- B. Let me see if I can find someone to help you.
- C. You cannot only make changes to your will after 3 weeks.
- D. Let's call your lawyer first and see what he thinks they think.
Correct Answer: B
Rationale: The nurse should assist the client by finding someone to help (B), such as a social worker or legal resource, to facilitate changes to the living will. There are no time restrictions (A, C), and contacting a lawyer (D) is unnecessary unless requested by the client.
The nurse is triaging clients in the emergency department (ED). Which client should the nurse triage as emergent? A client
- A. reporting pleuritic chest pain with a productive cough.
- B. who is pregnant and reporting intermittent nausea and vomiting.
- C. who has an isolated area of reddened vesicles and malaise.
- D. with sudden onset of ataxia and dysarthria.
Correct Answer: D
Rationale: Sudden ataxia and dysarthria (D) suggest a stroke, an emergent condition requiring immediate triage for time-sensitive intervention. Pleuritic cough (A), pregnancy nausea (B), and vesicles/malaise (C) are less urgent.