Nokea
The nurse is teaching a group of students about incident reports. Which of the following statements made by the student would require further teaching?
- A. Reporting can only be completed if it is within one hour after the event.
- B. Witnesses to an incident should be mentioned in the report.
- C. A client eloping does not require an incident report.
- D. A slip and fall by a client should be reported.
- E. Incidents involving visitors do not have to be reported.
Correct Answer: A, C, E
Rationale: Incident reports can be filed anytime, elopement requires reporting, and visitor incidents should be reported.
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The following scenario applies to the next 6 items
The nurse in the emergency department (ED) is caring for a 64-year-old male client.
Item 1 of 6
Nurses' Notes
1742: Client arrives at the emergency department via emergency medical services (EMS). He was skiing and crashed into a post and fell to the ground. Ski patrol assessed the client, and the client was confused and had no memory of the crash. Ski patrol reports that he was wearing a helmet and had a loss of consciousness for an unknown amount of time. On assessment, the client was alert and oriented to place and time but did not recall the events leading up to hospitalization, specifically the ski crash. Client states, “My head really hurts and I'm dizzy.” Reporting aching pain rated 8/10 on the Numerical Pain Scale. Reddish contusion on the client's forehead. Pupils were 2+, equal, and sluggishly reactive to light. Glasgow Coma Scale 14. Nose is midline and symmetrical. His speech was clear and articulate. Full range of motion in all extremities observed. Clear lung fields bilaterally. Radial pulse 2+ and irregular. Normoactive bowel sounds in all quadrants. No abdominal distention or pain. Vital signs: T 97.8° F (36.6° C), P 85, RR 15, BP 124/82, pulse oximetry reading 98% on room air. The client has a medical history of essential hypertension, generalized anxiety disorder, atrial fibrillation, and chronic back pain.
Home medications
• multivitamin (MVI) 1 tablet PO daily
• fluoxetine 20 mg PO daily
• biotin 100 mcg PO daily
• pantoprazole 40 mg PO daily
• warfarin 2.5 mg PO daily
• diltiazem controlled-release 120 mg PO daily
Which of the following assessment findings require immediate follow-up?
- A. lung sounds
- B. pupil assessment
- C. abdominal assessment findings
- D. pulse, respirations, and blood pressure
- E. Glasgow coma scale
- F. speech characteristics
- G. home medications
Correct Answer: B, E, G
Rationale: Pupil sluggishness, Glasgow Coma Scale of 14, and warfarin use (increasing bleeding risk) require immediate follow-up due to potential traumatic brain injury.
The nurse is caring for a client who has developed retinal detachment. Which of the following actions should the nurse take first?
- A. Instruct the client to restrict activity
- B. Establish a vascular access device
- C. Review the client's current medications
- D. Educate the client about topical eye ointments
Correct Answer: A
Rationale: Restricting activity is the first priority to prevent further retinal damage.
The nurse is planning a staff development conference about diabetic ketoacidosis (DKA). Which of the following information should the nurse include?
- A. The goal is to lower blood glucose by 50 to 75 mg/dL/hr (2.775 to 4.165 mmol/L/hr).
- B. Dextrose 5% in water (D5W) should be available to treat symptoms of hypoglycemia.
- C. Hypovolemia caused by DKA may be treated with 3% saline.
- D. The urine output would increase once regular insulin is initiated.
Correct Answer: A, B, D
Rationale: The goal is to lower glucose gradually, D5W treats hypoglycemia, and insulin increases urine output by correcting osmotic diuresis. 3% saline is not used for hypovolemia in DKA.
The nurse in the emergency department (ED) is caring for a 64-year-old male client.
Item 3 of 6
Nurses' Notes
1742: Client arrives at the emergency department via emergency medical services (EMS). He was skiing and crashed into a post and fell to the ground. Ski patrol assessed the client, and the client was confused and had no memory of the crash. Ski patrol reports that he was wearing a helmet and had a loss of consciousness for an unknown amount of time. On assessment, the client was alert and oriented to place and time but did not recall the events leading up to hospitalization, specifically the ski crash. Client states, “My head really hurts and I'm dizzy.” Reporting aching pain rated 8/10 on the Numerical Pain Scale. Reddish contusion on the client's forehead. Pupils were 2+, equal, and sluggishly reactive to light. Glasgow Coma Scale 14. Nose is midline and symmetrical. His speech was clear and articulate. Full range of motion in all extremities observed. Clear lung fields bilaterally. Radial pulse 2+ and irregular. Normoactive bowel sounds in all quadrants. No abdominal distention or pain. Vital signs: T 97.8° F (36.6° C), P 85, RR 15, BP 124/82, pulse oximetry reading 98% on room air. The client has a medical history of essential hypertension, generalized anxiety disorder, atrial fibrillation, and chronic back pain.
Home medications
• multivitamin (MVI) 1 tablet PO daily
• fluoxetine 20 mg PO daily
• biotin 100 mcg PO daily
• pantoprazole 40 mg PO daily
• warfarin 2.5 mg PO daily
• diltiazem controlled-release 120 mg PO daily
Complete the following sentence by choosing from the list of options. The nurse should prioritize obtaining an order for a ___ and ___ to better determine the extent of the client's injuries.
- A. radiograph (x-ray) of the head and neck
- B. electrocardiogram
- C. electroencephalogram
- D. computed tomography scan of the head
- E. hematocrit
- F. platelet count
- G. international normalized ratio
Correct Answer: D, G
Rationale: A CT scan of the head is critical to assess for brain injury, and INR is necessary due to warfarin use and bleeding risk.
The following scenario applies to the next 1 items
The nurse in the obstetrics department is caring for a 29-year-old primigravida client.
Item 1 of 1
History and Physical
2300: Client is a primigravida at 33 weeks gestation, who awoke to moderate bright red vaginal bleeding. She reports noticing light spotting earlier in the day, which she dismissed as benign. She denies abdominal pain, cramping, or contractions. Her pregnancy has been uncomplicated until recently. She reports increased fetal movement over the last 48 hours. One week ago, she presented to the ED with fever, fatigue, and body aches, and was diagnosed with influenza A. She was treated supportively and discharged home with hydration instructions. Over the past 24 hours, she has experienced nasal congestion and fatigue.
Four days ago, a transabdominal ultrasound showed:
• Fetus in cephalic position
• Normal amniotic fluid volume
Exam findings
• Abdomen: Soft, non-tender
• No uterine contractions noted on palpation
• Moderate amount of dried bright red blood was seen on the undergarments
• 1+ pedal edema
• Peripheral pulses 2+
•
Diagnostics
2342: Fetal Heart Rate (FHR): 144 bpm, moderate variability, no decelerations
Vital Signs
• Temperature: 99.5°F (37.5°C)
• HR 88 bpm
• BP 137/78 mmHg
• RR 18/min
• Pulse oximetry 98% on room air
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two (2) actions the nurse should take to address that condition, and two (2) parameters the nurse should monitor to assess the client's progress.
- A. Request a prescription for indomethacin, Prepare the client for a transvaginal ultrasound, Place the client in the lithotomy position for a manual cervical exam, Establish a peripheral vascular access device, Place the client in a room with monitored negative airflow
- B. Placental abruption, Preeclampsia, Placenta previa, Influenza recurrence
- C. Fetal heart rate pattern, Pedal edema, Amount and color of vaginal bleeding, Temperature, Nasal congestion and fatigue level
Correct Answer: C (placenta previa), A (prepare for transvaginal ultrasound, establish peripheral vascular access device), C (fetal heart rate pattern, amount and color of vaginal bleeding)
Rationale: Moderate bright red vaginal bleeding without pain at 33 weeks suggests placenta previa. Transvaginal ultrasound confirms the diagnosis, peripheral access prepares for potential intervention, and monitoring fetal heart rate and bleeding assesses progress.