Nokea
The nurse is caring for assigned clients. The nurse should initially assess the client who
- A. is recovering from a femoral angioplasty and reports their foot is falling asleep.
- B. has diabetes mellitus and refused their prescribed glargine insulin.
- C. received alteplase three hours ago for a stroke and has a Glasgow Coma Scale of 14.
- D. had a T6 spinal cord injury and has not had a bowel movement since yesterday.
Correct Answer: A
Rationale: Numbness post-femoral angioplasty (A) suggests vascular compromise, such as occlusion, requiring immediate assessment. Insulin refusal (B), stable GCS post-alteplase (C), and constipation in spinal injury (D) are less urgent.
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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.
The registered nurse (RN) is orienting a new RN to the charge nurse role. When delegating tasks, which task delegated to the licensed practical/vocational nurse (LPN/VN) would require follow-up from the charge nurse?
- A. Obtaining an occult stool sample for a client with ulcerative colitis.
- B. Assessing a newly admitted client with chest pain.
- C. Reinforcing teaching to a client newly diagnosed with diabetes mellitus.
- D. Providing pin care for a client with external fixation of the wrist.
Correct Answer: B
Rationale: Assessing a new client with chest pain (B) requires RN-level judgment due to potential life-threatening conditions, necessitating follow-up if delegated to an LPN. Stool sample collection (A), reinforcing teaching (C), and pin care (D) are within LPN scope.
The nurse in the emergency department (ED) is reviewing triage data for assigned clients. The nurse should initially follow up on the client who
- A. is requesting screening for pulmonary tuberculosis after traveling domestically in the United States.
- B. is being treated for a diabetic foot ulcer and requires a dressing change.
- C. is pregnant and has a fever accompanied by a generalized vesicular rash.
- D. is concerned they may have acquired human immunodeficiency virus (HIV) following unprotected sexual activity.
Correct Answer: C
Rationale: A pregnant client with fever and vesicular rash (C) suggests possible varicella or herpes, posing risks to mother and fetus, requiring immediate follow-up. TB screening (A), foot ulcer dressing (B), and HIV concern (D) are less urgent, as they are preventive or chronic.
The nurse in the emergency department (ED) is caring for a client experiencing septic shock. The nurse should prioritize
- A. obtaining an order to insert an indwelling urethral catheter.
- B. monitoring the client's serum white blood cell count and lactic acid.
- C. establishing frequent blood pressure monitoring.
- D. monitoring the client's capillary blood glucose.
Correct Answer: C
Rationale: Frequent BP monitoring (C) is the priority in septic shock to assess hemodynamic stability and guide fluid/vasopressor therapy, per Surviving Sepsis guidelines. Catheter insertion (A), lab monitoring (B), and glucose checks (D) are secondary to immediate circulatory assessment.
The nurse is caring for assigned clients. The nurse should first assess the client
- A. with a right femur fracture who reports pain rated as 4 on a scale of 0 (no pain) to 10 (severe pain).
- B. with chronic obstructive pulmonary disease (COPD) who is reporting shortness of breath while ambulating in the hallway.
- C. with a history of T6 spinal injury 6 months ago, now reports a severe headache and is diaphoretic.
- D. one day postoperative from an open cholecystectomy with green drainage from the t-tube.
Correct Answer: C
Rationale: Severe headache and diaphoresis in a T6 spinal injury (C) suggest autonomic dysreflexia, a life-threatening emergency. COPD shortness of breath (B), femur fracture pain (A), and t-tube drainage (D) are less urgent.