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While caring for a client who requires a mechanical ventilator for breathing, the high-pressure alarm goes off on the ventilator. What is the first action the nurse should perform?
- A. Disconnect the client from the ventilator and use a manual resuscitation bag.
- B. Perform a quick assessment of the client's condition.
- C. Call the respiratory therapist for help.
- D. Press the alarm reset button on the ventilator.
Correct Answer: B
Rationale: A high-pressure alarm suggests obstruction or resistance, so assessing the client’s condition (B) first identifies the cause (e.g., tube kinking, secretions). Disconnecting (A), calling for help (C), or resetting (D) without assessment risks harm or delays resolution.
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A medication error has occurred in the medical ward. After a thorough investigation was performed, the nurse manager posts a memorandum regarding changes in medication administration to be implemented immediately. The nurses on the unit recognized this management style as:
- A. Autocratic
- B. Democratic
- C. Participative
- D. Laissez-faire
Correct Answer: A
Rationale: Posting a memorandum with immediate changes (A) reflects an autocratic management style, where the manager makes decisions unilaterally. Democratic (B) and participative (C) involve staff input, while laissez-faire (D) lacks direction.
The nurse is caring for a client taking prescribed captopril. Which abnormal laboratory value should the nurse prioritize when notifying the healthcare provider?
- A. Serum creatinine 1.3 mg/dL (114.92 μmol/L) [Male: 0.6-1.2 mg/dL, Female: 0.5-1.1 mg/dL, Male 49-93 μmol/L, Female 22-75 μmol/L]
- B. Serum potassium 5.2 mEq/L (mmol/L) [3.5-5 mEq/L (mmol/L)]
- C. Serum phosphorus 4.6 (1.48 mmol/L) [2.5-4.5 mg/dL, 0.81-1.58 mmol/L]
- D. Blood glucose 135 mg/dL (7.5 mmol/L) [70-110 mg/dL, 4-6 mmol/L]
Correct Answer: B
Rationale: Hyperkalemia (potassium 5.2 mEq/L, B) is a priority with captopril, an ACE inhibitor, as it can cause life-threatening arrhythmias. Creatinine (A) and phosphorus (C) are slightly elevated but less urgent. Glucose (D) is elevated but not critical in this context.
A registered nurse (RN) and a licensed practical/vocational nurse (LPN/VN) are caring for a client who is violent and self-discontinued their peripheral vascular access. After initiating physical wrist restraints, which of the following tasks may the RN delegate to the LPN?
- A. Collect data on the client's skin integrity.
- B. Educate the client on the need for restraints.
- C. Initiate peripheral vascular access.
- D. Continually assess the client to determine if restraint use is necessary.
Correct Answer: A
Rationale: Collecting data on skin integrity (A) is within the LPN’s scope for monitoring restraint effects. Education (B) and ongoing restraint necessity assessment (D) require RN judgment, and initiating vascular access (C) may be outside LPN scope depending on state regulations.
The emergency department (ED) nurse is caring for a client admitted with diabetic ketoacidosis (DKA). Which clinical data requires immediate follow-up?
- A. Respiratory rate (RR) 23/minute
- B. Capillary blood glucose 319 mg/dL (17.70 mmol/L) [70-110 mg/dL, 4.0-11.0 mmol/L]
- C. Mean arterial pressure (MAP) 51 mm Hg
- D. PaO2 90 mm Hg [80-100 mm Hg]
Correct Answer: C
Rationale: A MAP of 51 mm Hg in DKA (C) indicates severe hypotension and organ hypoperfusion, requiring immediate fluid resuscitation. RR 23 (A) and glucose 319 (B) are expected in DKA, and PaO2 90 (D) is normal, none requiring immediate action.
The nurse is caring for a client who fell off the ladder. The client reports numbness in his lower extremities. The nurse should initially
- A. assess the client for lacerations
- B. evaluate the range of motion of the client's neck
- C. provide cervical spine stabilization
- D. assess the client's range of motion in the lower extremities
Correct Answer: C
Rationale: Numbness in lower extremities suggests spinal cord injury, requiring immediate cervical spine stabilization (C) to prevent further damage. Assessing lacerations (A), neck range of motion (B), or lower extremity motion (D) risks exacerbating injury.