Nokea
The nurse is caring for assigned clients. The nurse should initially assess the client who was admitted for
- A. intermittent chest pain fourteen hours ago, and the most recent serial troponin level showed no elevation.
- B. syndrome of inappropriate antidiuretic hormone (SIADH) and has developed disorientation within the last two hours.
- C. an acute kidney injury (AKI) four hours ago and has been urinating 15 mL/hr in the indwelling urinary catheter.
- D. observation following a laparoscopic cholecystectomy six hours ago, reporting abdominal cramping radiating to the shoulder.
Correct Answer: B
Rationale: New disorientation in SIADH (B) suggests severe hyponatremia, a neurological emergency requiring immediate assessment. Non-elevated troponin (A), oliguria in AKI (C), and post-cholecystectomy pain (D) are less urgent, though AKI requires monitoring.
You may also like to solve these questions
The most frequent threat to technological and information security in a healthcare facility is which of the following?
- A. Computer hacking by a foreign country
- B. Computer hacking by a United States citizen for ransom
- C. Failure of employees to log off computer systems and sharing of passwords with others
- D. A major electrical failure in the facility
Correct Answer: C
Rationale: Failure to log off or sharing passwords (C) is the most common security threat, as it allows unauthorized access to protected health information. Hacking (A, B) is less frequent, and electrical failure (D) impacts operations but not information security directly.
The registered nurse (RN) observes licensed practical/vocational nurses (LPN/VN) care for assigned clients. Which of the following actions by the LPN would require the RN to intervene? Select all that apply.
- A. Irrigates an indwelling catheter with warm tap water.
- B. Administers glargine insulin for a client with nothing by mouth (NPO) status.
- C. Obtains a 12-lead electrocardiogram for a client with hyperkalemia.
- D. Clamps a chest tube while the client ambulates.
- E. Repositions a client who requires log rolling by using a gait belt.
Correct Answer: A, B, D, E
Rationale: Irrigating with tap water (A) risks infection, insulin for NPO client (B) risks hypoglycemia without RN assessment, clamping a chest tube (D) risks pneumothorax, and using a gait belt for log rolling (E) is incorrect technique. ECG (C) is within LPN scope.
During a disaster triage situation with limited ICU beds and resources, the nurse must recommend which clients should receive priority for ICU admission. Which of the following clients should be prioritized? Select all that apply.
- A. A client with a flail chest and respiratory distress requiring intubation
- B. A client with a Glasgow Coma Scale (GCS) score of 3 and fixed pupils
- C. A client with septic shock responding to vasopressors and fluids
- D. A client with extensive full-thickness burns over 85% of the total body surface area
- E. A client with an open leg fracture and stable vital signs
- F. A client with a traumatic brain injury and signs of increasing intracranial pressure
Correct Answer: A, C, F
Rationale: Clients with flail chest requiring intubation (A), septic shock responding to treatment (C), and traumatic brain injury with increasing intracranial pressure (F) have salvageable conditions needing ICU care. GCS of 3 with fixed pupils (B) indicates poor prognosis, extensive burns (D) have low survival likelihood, and stable leg fracture (E) is non-critical.
The charge nurse is supervising unlicensed assistive personnel (UAPs). The charge nurse should immediately intervene when a UAP is observed
- A. assisting a client with multiple sclerosis to shower.
- B. applying a condom catheter to a client who is incontinent.
- C. transporting a client with myocardial infarction to the cardiac catheterization lab.
- D. obtaining vital signs for a client with delirium.
Correct Answer: C
Rationale: Transporting a client with myocardial infarction (C) by a UAP is unsafe, as they require continuous monitoring for cardiac instability. Shower assistance (A), condom catheter application (B), and vital signs (D) are within UAP scope.
The nurse is caring for the following assigned clients. It would be a priority to follow up with a client who
- A. has atrial fibrillation and a heart rate of 112/minute.
- B. has glomerulonephritis with a blood pressure of 137/86 mm Hg.
- C. is receiving amphotericin B, and the most recent temperature is 100.4°F (38°C).
- D. has chronic obstructive pulmonary disease (COPD) with an oxygen saturation of 91% on room air.
Correct Answer: A
Rationale: Atrial fibrillation with a heart rate of 112/minute (A) indicates a rapid ventricular response, risking hemodynamic instability or stroke, requiring immediate rate control. Glomerulonephritis with normal BP (B), mild fever with amphotericin (C), and COPD with 91% saturation (D) are less urgent, as they are stable or expected.