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The nurse is caring for a client with suspected sepsis. After reviewing the client's vital signs, which prescription by the primary healthcare provider (PHCP) should the nurse administer first? See the images below.
- A. Ceftriaxone
- B. Doxycycline
- C. Acetaminophen
- D. 0.9% sodium chloride (normal saline) bolus
Correct Answer: D
Rationale: This client is in shock. A blood pressure of 90/60 mm Hg is clinical hypotension combined with the client's tachycardia. The client needs immediate fluid volume resuscitation to prevent further clinical decline. Sepsis is a medical emergency, and the client will require prompt antibiotics. Still, it will not prioritize treating the client's hypovolemia which is the immediate concern illustrated by the low blood pressure.
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The nurse is preparing to discharge clients from the nursing unit. Which client has the greatest need to be referred for outpatient community services?
- A. A client newly diagnosed with skin cancer that lives with family.
- B. A client recovering from a stroke and is discharged to inpatient rehab.
- C. A client who is homeless and has a substance use disorder.
- D. A client leaving against medical advice for the treatment of cellulitis.
Correct Answer: C
Rationale: A homeless client with substance use disorder (C) has the greatest need for outpatient services to address social determinants and prevent relapse. Skin cancer with family (A), stroke rehab (B), and AMA cellulitis (D) have alternative support or less urgent needs.
The nurse is reviewing tasks for assigned clients. Which action is a priority to implement?
- A. Visual acuity test for a client reporting blurred vision in one eye.
- B. 12-lead electrocardiogram for a client reporting chest pain.
- C. Orthostatic vital signs for a client complaining of syncope.
- D. Discharge teaching for a client newly diagnosed with hypertension.
Correct Answer: B
Rationale: A 12-lead ECG for chest pain (B) is the priority to rule out life-threatening cardiac events like myocardial infarction. Blurred vision (A), syncope (C), and discharge teaching (D) are less urgent, as they are not immediately life-threatening.
The emergency department (ED) nurse cares for a client with diabetes mellitus (type one) with diabetic ketoacidosis (DKA). Which assessment finding requires immediate follow-up?
- A. Pulse 112/minute
- B. Nausea and vomiting
- C. Respiratory rate 21/minute
- D. Blood glucose 299 mg/dL (16.5 mmol/L) [70-110 mg/dL (4-6 mmol/L)]
Correct Answer: B
Rationale: Nausea and vomiting in DKA (B) can worsen dehydration and electrolyte imbalances, requiring immediate follow-up. Tachycardia (A) and tachypnea (C) are expected, and glucose of 299 (D) is consistent with DKA but less urgent.
The nurse has attended a staff education program about incident reporting. It would indicate effective understanding if the nurse states that the primary purpose of incident reporting is to
- A. implement corrective measures needed to prevent recurrence.
- B. collect data about errors and compare it to different time periods.
- C. communicate the error(s) to other departments within the facility.
- D. notify the individual involved of the deviation from the standard of care.
Correct Answer: A
Rationale: The primary purpose of incident reporting (A) is to implement corrective measures to prevent recurrence, enhancing client safety. Data collection (B), interdepartmental communication (C), and individual notification (D) are secondary benefits of the reporting process.
The nurse in the emergency department (ED) is caring for a client who intentionally overdosed on their prescribed lithium. The nurse plans on initially
- A. developing a therapeutic rapport with the client.
- B. inserting a peripheral vascular access device.
- C. obtaining the client’s vital signs.
- D. collecting a serum lithium level on the client.
Correct Answer: B
Rationale: Inserting a peripheral vascular access device (B) is the initial priority in a lithium overdose to enable rapid administration of fluids or medications to stabilize the client. Vital signs (C) and lithium levels (D) follow, and rapport (A) is secondary to medical stabilization.