Nokea
The nursing assistant is taking vitals for a client on mechanical ventilation. Which of the following findings should the nursing assistant report to the nurse immediately?
- A. respiratory rate 26 breaths/minute
- B. heart rate 82 beats/minute
- C. blood pressure 152/86 mmHg
- D. temperature 102.1°F
Correct Answer: D
Rationale: Fever (102.1°F) in a ventilated client suggests infection (e.g., ventilator-associated pneumonia), requiring immediate reporting.
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A client is prescribed heparin 2,000 units SC q8 hours. The pharmacy sends heparin 5,000 units/mL. How many mL should the nurse administer every 24 hours?
- A. 0.4 mL/day
- B. 0.8 mL/day
- C. 1.2 mL/day
- D. 1.4 mL/day
Correct Answer: C
Rationale: Dose per injection: 2,000 units ÷ 5,000 units/mL = 0.4 mL. Q8 hours = 3 doses/day. 0.4 mL × 3 = 1.2 mL/day.
When determining whether or not a client is a candidate for restraints, which of the following would be considered an appropriate reason for a restraint?
- A. Current dangerous behavior
- B. History of falls
- C. Recent violent attack on a staff member
- D. Refusal to cooperate with treatment
Correct Answer: A
Rationale: Restraints are justified for current dangerous behavior (A) posing immediate risk to self or others. History of falls (B), past violence (C), or non-cooperation (D) do not warrant restraints.
A client with cancer is admitted to the oncology unit. Stat lab values reveal Hgb 12.6, WBC 6500, K+ 1.9, uric acid 7.0, Na+ 136, and platelets 178,000. The nurse evaluates that the client is experiencing which of the following?
- A. Hypernatremia
- B. Hypokalemia
- C. Myelosuppression
- D. Leukocytosis
Correct Answer: B
Rationale: A potassium level of 1.9 mEq/L indicates hypokalemia, which is a critical electrolyte imbalance.
Which statement is true regarding balanced skeletal traction? Balanced skeletal traction:
- A. Utilizes a Steinman pin
- B. Requires that both legs be secured
- C. Utilizes Kirschner wires
- D. Is used primarily to heal the fractured hips
Correct Answer: A
Rationale: Balanced skeletal traction commonly uses a Steinman pin to stabilize fractures.
Someone sees a nursing assistant yell at an elderly client and throw his lunch tray off the table. The nursing assistant could likely be charged with
- A. negligence.
- B. assault.
- C. malpractice.
- D. battery.
Correct Answer: B
Rationale: Yelling and throwing a tray constitute assault (threatening behavior causing fear of harm). Battery involves physical contact, negligence involves failure to act, and malpractice applies to professional errors.