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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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The nurse is caring for assigned clients. The nurse should initially follow-up on the client who
- A. has a blood glucose of 250 mg/dL (13.875 mmol/L) while being treated with prednisone for pneumonia.
- B. is receiving a continuous infusion of heparin and has a 50% reduction in platelets over the past five days.
- C. has diabetes mellitus (type two) and reports burning and tingling in both feet.
- D. is being treated for acute post-streptococcal glomerulonephritis and has an hourly urinary output of 20 ml/hr.
Correct Answer: B
Rationale: A 50% platelet drop on heparin (B) suggests heparin-induced thrombocytopenia, a life-threatening condition requiring immediate cessation of heparin. Hyperglycemia (A), neuropathy (C), and low urine output (D) are concerning but less acute, as they are expected or manageable with less urgency.
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 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.
The nurse is reviewing leadership and management concepts with a student nurse. Which of the following statements by the student nurse would require follow-up?
- A. The Laissez-faire leadership style is a passive leadership approach.
- B. A registered nurse (RN) may delegate accountability to a licensed practical/vocational nurse (LPN/VN).
- C. The rights of delegation include task, circumstance, person, direction, supervision.
- D. The nurse practice act defines roles and responsibilities of nursing professionals.
Correct Answer: B
Rationale: The statement that RNs can delegate accountability to LPNs (B) is incorrect, as RNs remain accountable for delegated tasks. Laissez-faire leadership (A), delegation rights (C), and nurse practice acts (D) are accurately described, requiring no follow-up.
The nurse is caring for assigned clients in the mental health unit. The nurse should initially follow up on the client who
- A. is admitted for psychosis and is pacing in the hallway, mumbling to themselves.
- B. is being treated for obsessive compulsive disorder and has increased the number of times they wash their hands.
- C. has a substance use disorder and refuses to attend group therapy for the second time.
- D. is diagnosed with borderline personality disorder and is insisting on seeing the charge nurse for an allegation of abuse two days ago.
Correct Answer: A
Rationale: Pacing and mumbling in psychosis (A) suggest agitation or worsening symptoms, posing a safety risk requiring immediate follow-up. Increased hand washing (B), therapy refusal (C), and abuse allegations (D) are less urgent, as they are chronic or procedural.