Nokea
The nurse is reviewing laboratory data for assigned clients. Which laboratory result requires immediate follow-up with the primary healthcare provider (PHCP)?
- A. Elevated amylase result in a client diagnosed with acute pancreatitis
- B. Elevated white blood cell (WBC) count in a client with an infected leg wound.
- C. Urinalysis positive for leukocytes and nitrites for a client receiving chemotherapy
- D. Serum glucose of 235 mg/dL (13.05 mmol/L) [70-110 mg/dL; 4-6 mmol/L] in a client with diabetes mellitus (type one)
Correct Answer: C
Rationale: Leukocytes and nitrites in urinalysis for a chemotherapy client (C) indicate a possible urinary tract infection, critical due to immunosuppression. Elevated amylase (A) and WBC (B) are expected, and glucose of 235 (D) is elevated but less urgent.
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The nurse in the emergency department (ED) is assessing a client involved in a motor vehicle crash who sustained a penetrating abdominal trauma. The client’s vital signs are: T 97.5°F (36.4°C); P 108 bpm; RR 22; BP 98/64 mm Hg; pulse oximetry 94% on room air. Which of the following actions should the nurse take first?
- A. Prepare the client for surgery.
- B. Insert a nasogastric (NG) tube.
- C. Auscultate the client’s bowel sounds.
- D. Reassess vital signs.
Correct Answer: D
Rationale: Reassessing vital signs (D) is the first action to confirm stability or deterioration in a client with penetrating abdominal trauma and tachycardia/hypotension, guiding further interventions. Surgery prep (A), NG tube (B), and bowel sounds (C) follow reassessment.
The nurse is precepting a graduate nurse as they perform resuscitation on an adult with cardiac arrest. Which action by the graduate requires immediate follow-up by the nurse?
- A. Assesses the client’s pulse by palpating the carotid artery.
- B. Allows for chest recoil after every chest compression.
- C. Compresses at a depth of 2 inches on the center breastbone.
- D. Asks for an automated external defibrillator after one cycle of CPR.
Correct Answer: C
Rationale: Compressing at a depth of 2 inches (C) is inadequate for adult CPR, as guidelines require 2.4 inches (6 cm) for effective circulation, requiring immediate correction. Pulse check (A), chest recoil (B), and requesting a defibrillator (D) are correct actions.
A hospitalized client tells the nurse that she has a living will prepared and that her lawyer will be bringing the will to the hospital today for witness signatures. The client asks the nurse to help her obtain a witness for the will. Which of the following is the most appropriate response?
- A. I will sign as a witness to your signature.'
- B. Because it is a legal document, you will need to find a witness on your own.'
- C. Whoever is present at the time will sign as a witness for you.'
- D. I will contact the nursing supervisor for assistance regarding your request.'
Correct Answer: D
Rationale: Contacting the nursing supervisor (D) ensures compliance with legal witnessing requirements, as nurses may be restricted due to conflict of interest. Signing as a witness (A), leaving it to the client (B), or allowing anyone present (C) risks legal issues.
The nurse manager plans to develop a unit-based council to assist in decision-making. The nurse manager is demonstrating which leadership style?
- A. Authoritative
- B. Democratic
- C. C. Laissez-Faire
- D. D. Transactional
Correct Answer: B
Rationale: A unit-based council reflects a democratic leadership style (B), involving staff in decision-making. Authoritative (A) is directive, laissez-faire (C) is passive, and transactional (D) focuses on rewards and tasks, not shared governance.
The registered nurse (RN) is planning client care assignments. Which client would be appropriate to assign to the licensed practical/vocational nurse (LPN/VN)? A client
- A. with Guillain-Barre syndrome client reporting dyspnea while at rest.
- B. with stage 3 and 4 pressure injuries present in the sacral area.
- C. 2 hours postoperative total laryngectomy.
- D. awaiting a referral for outpatient diabetic support services.
Correct Answer: D
Rationale: A client awaiting a referral for diabetic support services (D) is stable and suitable for LPN care, involving coordination within scope. Guillain-Barré syndrome with dyspnea (A), severe pressure injuries (B), and recent laryngectomy (C) require RN assessment due to critical or complex needs.