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Which client requires the most immediate intervention by the nurse?
- A. An older adult receiving enteral feedings via feeding tube who has a temperature of 100.6°F (38.1°C).
- B. A client with acute kidney injury who is somnolent and does not respond to verbal commands.
- C. A young adult who experienced heat stroke and is receiving a normal saline intravenous (IV) fluid bolus.
- D. A pregnant client with hyperemesis gravidarum who is receiving an infusion of Ringer's Lactate.
Correct Answer: B
Rationale: The client with acute kidney injury and unresponsiveness likely has uremic encephalopathy, a life-threatening condition requiring immediate intervention. The other clients' conditions are less urgent as they are receiving appropriate treatments.
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A 5-year-old boy with mumps is being transferred to the pediatric unit. Which nursing intervention is most important for the nurse to implement?
- A. Place an isolation cart outside of the room to initiate droplet precautions.
- B. Schedule bedside play time with the occupational therapist.
- C. Instruct the child's parents about the need for transmission precautions.
- D. Assign the child to a room close to the nurse's station.
Correct Answer: A
Rationale: Initiating droplet precautions with an isolation cart prevents mumps transmission, a priority for infection control. Play time, parent instruction, and room assignment are secondary.
It is most important to assign which client to a registered nurse rather than a practical nurse (PN)?
- A. One hour after receiving hydromorphone prescribed for every 4 hours PRN use, a client reports severe pain.
- B. Two hours after receiving morphine for acute pain, a client's vital signs are BP 112/60 mm Hg, pulse 88 beats/minute, and respirations 14 breaths/minute.
- C. After ambulating, a postoperative client grimaces and reports incisional pain at a '9 on a ten-point scale'.
- D. The fentanyl transdermal patch for a client with chronic cancer pain needs to be replaced.
Correct Answer: C
Rationale: The postoperative client with severe pain requires immediate RN assessment and intervention due to potential complications. The other clients' needs (PRN medication, stable vitals, routine patch replacement) can be managed by a PN under supervision.
The unlicensed assistive personnel (UAP) reports to the nurse that a male client with fluid volume overload will not allow the UAP to obtain his daily weight. Which action should the nurse implement?
- A. Ask the client why he does not want to be weighed.
- B. Instruct the UAP to weigh the client using a bed scale.
- C. Direct the UAP to delay weighing the client until later.
- D. Document that the client refused daily weights.
Correct Answer: B
Rationale: Using a bed scale accommodates the client's condition, ensuring accurate weight measurement without discomfort. Asking why, delaying, or documenting refusal do not address the need for timely data to monitor fluid status.
After reviewing the morning laboratory findings for four clients, which client should the nurse follow up with first? Reference Range: International Normalized Ratio [0.8 to 1.1], Blood Glucose 74 to 106 mg/dL (4.1 to 5.9 mmol/L)], Potassium [3.5 to 5 mEq/L (3.5 to 5 mmol/L)], Brain Natriuretic Peptide (BNP) [less than 100 pg/mL (less than 100 ng/L)]
- A. The brain natriuretic peptide (BNP) assay for a client with shortness of breath after a myocardial infarction (MI) increases to 1000 pg/mL (1000 ng/L).
- B. The international normalized ratio (INR) for a client who is receiving warfarin therapy increases to 2.5.
- C. The serum glucose level for a client receiving corticosteroids increases to 150 mg/dL (8.3 mmol/L).
- D. The potassium level for a client scheduled for renal dialysis increases to 5 mEq/L(5 mmol/L).
Correct Answer: A
Rationale: A BNP of 1000 pg/mL indicates severe heart failure, requiring urgent interventions like oxygen and diuretics. The INR is therapeutic, glucose is mildly elevated, and potassium is normal, making these less urgent.
A charge nurse is making client assignments in the Intensive Care Department. The healthcare team consists of one nurse with 10 years experience, one nurse with 5 years experience, and a new graduate nurse who just completed a 12-week internship. Which client should the nurse assign to the new graduate nurse?
- A. A client with multisystem failure secondary to a motor vehicle collision.
- B. A client in end-stage liver failure who is experiencing esophageal bleeding.
- C. A client with Adult Respiratory Distress Syndrome who is on a ventilator.
- D. A client with chest tubes secondary to a stab wound to the chest.
Correct Answer: D
Rationale: The client with chest tubes has stable needs manageable by a new graduate with recent training. Multisystem failure, liver failure, and ARDS require advanced skills better suited to experienced nurses.