Nokea
The nurse is caring for assigned clients. The nurse should initially follow-up on the client who
- A. has a blood glucose of 250 mg/dL (13.875 mmol/L) while being treated with prednisone for pneumonia.
- B. is receiving a continuous infusion of heparin and has a 50% reduction in platelets over the past five days.
- C. has diabetes mellitus (type two) and reports burning and tingling in both feet.
- D. is being treated for acute post-streptococcal glomerulonephritis and has an hourly urinary output of 20 ml/hr.
Correct Answer: B
Rationale: A 50% platelet drop on heparin (B) suggests heparin-induced thrombocytopenia, a life-threatening condition requiring immediate cessation of heparin. Hyperglycemia (A), neuropathy (C), and low urine output (D) are concerning but less acute, as they are expected or manageable with less urgency.
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The charge nurse is making assignments in the intensive care unit (ICU) and is making client assignments for a nurse floated from the medical-surgical (med-surg) unit. Which client would be appropriate to assign to the nurse floated from med-surg?
- A. A client with bacteremia who is suspected of developing shock.
- B. A client requiring the titration of intravenous (IV) vasopressors based on hemodynamic monitoring.
- C. A client receiving intravenous (IV) antibiotics and nebulizer treatments for pneumonia.
- D. A client with targeted temperature management three hours after experiencing cardiac arrest.
Correct Answer: C
Rationale: A client receiving IV antibiotics and nebulizers for pneumonia (C) is stable and aligns with med-surg skills, suitable for a float nurse. Bacteremia with shock (A), vasopressor titration (B), and targeted hypothermia (D) require ICU expertise.
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 a client who expresses feeling self-conscious about their hair and states they would like to wash it before undergoing diagnostic tests and procedures. How should the nurse prioritize the client's care?
- A. Offer the client a cap or scarf to cover their hair and suggest washing it after the diagnostic tests are complete.
- B. The nurse should schedule the testing and meal planning first and complete hygiene as time permits.
- C. Perform the dressing changes first, schedule testing, counsel, and complete hygiene last.
- D. Arrange to wash the client's hair first, perform hygiene, and then complete the diagnostic testing and counseling.
Correct Answer: A
Rationale: Offering a cap/scarf and suggesting washing later (A) addresses the client’s emotional needs while prioritizing timely diagnostics, ensuring medical care is not delayed. Scheduling tests first (B), prioritizing dressings (C), or washing hair first (D) either delays care or ignores efficiency.
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.