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The nurse is caring for a group of clients in the emergency department. Which client situation requires immediate follow-up? A client
- A. transdermal nitroglycerin applied for angina and newly nits reports a headache.
- B. receiving intravenous fluids for diabetic ketoacidosis and has an outstanding order for a regular insulin infusion.
- C. receiving a continuous infusion of esmolol for an abdominal aortic aneurysm and reports flank pain.
- D. who just received discharge orders and needs teaching on how to care for their fractured radius.
Correct Answer: B,C
Rationale: An outstanding insulin infusion order for diabetic ketoacidosis (B, C) is critical to prevent life-threatening metabolic deterioration. Flank pain with esmolol infusion (A) suggests aneurysm expansion or rupture, also urgent, but insulin (D) is more immediately actionable. Nitrate headaches (A) are common and benign, and discharge teaching (B) is non-urgent.
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The nurse in the family clinic is checking the vital signs of clients. Which client should the nurse prioritize?
- A. A 9-month-old baby with a pulse rate of 148
- B. A 2-year-old with a respiratory rate of 30
- C. A 24-week pregnant woman with a blood pressure of 148/96 mmHg
- D. A 40-year-old man with a temperature of 37.8°C (100.04°F)
Correct Answer: C
Rationale: A blood pressure of 148/96 mmHg in a 24-week pregnant woman (C) suggests preeclampsia, a priority for immediate assessment. A pulse of 148 (A) and respiratory rate of 30 (B) are normal for infants and toddlers, and a mild temperature (D) is less urgent.
The nurse is triaging phone calls at the mental health clinic. Which client situation requires immediate follow-up? A client prescribed
- A. olanzapine reporting muscle stiffness and feeling hot.
- B. haloperidol reporting blurred vision and constipation.
- C. clozapine reporting occasional twitches of the mouth.
- D. aripiprazole reporting feeling very restless.
Correct Answer: A
Rationale: Muscle stiffness and feeling hot with olanzapine (A) suggest neuroleptic malignant syndrome, a life-threatening emergency requiring immediate follow-up. Blurred vision/constipation (B), mouth twitches (C), and restlessness (D) are less urgent side effects.
The nurse in the emergency department (ED) is caring for a client and establishes continuous cardiac monitoring. Which initial action should the nurse take based on the electrocardiogram tracing? See the exhibit for additional client information.
- A. Establish vascular access and request a prescription for atropine
- B. Assess the client's blood pressure and level of consciousness
- C. Obtain and review the client's current medications
- D. Document the findings and reassess the client in one hour
Correct Answer: B
Rationale: Sinus bradycardia can be benign or symptomatic. The priority is to determine whether the client is hemodynamically stable by assessing blood pressure (BP) and level of consciousness (LOC). If the client is symptomatic (e.g., hypotension, dizziness, altered mental status), further interventions such as atropine administration may be required.
The emergency department (ED) nurse is caring for a client brought in after being found walking around a neighborhood without shoes, confused and disoriented. The nurse should initially
- A. obtain vital signs.
- B. perform a mental status exam.
- C. attempt to locate the client’s family.
- D. request an order for a psychiatry consultation.
Correct Answer: A
Rationale: Obtaining vital signs (A) is the initial priority to assess for physiological instability (e.g., hypothermia, hypoglycemia) in a confused client. Mental status exam (B), family contact (C), and psychiatry consult (D) follow after ensuring medical stability.
The nurse is caring for a child in the emergency department (ED) who sustained a bite from a rabid animal. The nurse should take which initial action
- A. Complete a detailed wound assessment
- B. Cleanse the wound with soap and water
- C. Obtain a prescription for an antibiotic
- D. Report the bite to animal control
Correct Answer: B
Rationale: Cleansing the wound with soap and water (B) is the initial action for a rabid animal bite to reduce viral load and infection risk, per CDC recommendations. Wound assessment (A), antibiotics (C), and reporting (D) follow initial cleaning.