The nurse witnesses the collapse of a child while outdoors. The child is not breathing and
has a pulse of 50/min. The nurse calls emergency services and initiates rescue breathing.
After 2 minutes of rescue breaths, the child is still not breathing and is pale with a pulse of
30/min. What is the nurse's next action? - ANSWER 1. Initiate chest compressions
Rescue breathing is performed at a rate of 1 breath every 2-3 seconds. If the pulse remains
<60/min and there are signs of poor perfusion (skin pallor), the nurse should initiate chest
compressions and reassess the pulse every 2 minutes
The charger nurse is responsible for making room assignments multiple clients. Which pari
of client assignments to a shared room is appropriate? - ANSWER 3. Client who had a
bowel resection 1 day ago and client with asthma exacerbation.
When making room assignments, it is important to remember that a client with an active or
suspected infection should not be paired with a client who has a fresh surgical wound or is
immunocompromised. A client having an asthma exacerbation does not have an infection
and is not at risk for spreading infection to a client who had a recent bowel resection
surgery.
The clinic nurse is assessing a client who is being treated for depression and suicidal
ideation. Which client statement best indicates that the client is not currently at risk for
suicide? - ANSWER 2. "I plan to attend my grandchild's graduation next month"
Clients receiving treatment for depression and suicidal ideation must be carefully monitored
for indications of increasing suicidal intent. During a client interview, the nurse should
assess:
1
,- Access to psychiatric medications
- Availability of help during a crisis (counselor, family)
- Future goals and plans
- Home and environment risks
- Overall affect and level of energy
- Possible access to weapons
Clients who articulate long-term personal goals and family milestones are less likely to
attempt death by suicide
The nurse is caring for a client who had an anterior wall myocardial infarction 2 days ago.
The telemetry technician notifies the nurse at 8:30 AM that the client is in ventricular
trigeminy. What is the nurse's priority intervention? - ANSWER 1. Administer
potassium supplement
In ventricular trigeminy, premature ventricular contractions (PVCs) occur every third
heartbeat. Myocardial injury (eg, myocardial infarction) predisposes the client to ectopy (eg,
PVCs), which increases the client's risk for lethal dysrhythmias (eg, ventricular tachycardia).
PVCs are caused and/or exacerbated by hypoxia, electrolyte imbalances, emotional stress,
stimulants, fever, and exercise.
This client's morning laboratory results show hypokalemia (potassium <3.5 mEq/L [3.5
mmol/L]); therefore, the priority is treatment of the underlying cause of the ectopy by
administering the prescribed potassium replacement (Option 1). Health care providers
(HCPs) often prescribe electrolyte replacement algorithms to clients at risk for electrolyte
imbalances (eg, myocardial injury, receiving diuretics) unless a contraindication exists (eg,
serum creatinine >1.5 mg/dL [133 µmol/L], anuric, weight <99.2 lb [45 kg]).
The nurse cares for a client with a terminal disease who created a do not attempt
resuscitation (DNAR) directive. The client stops breathing and loses their pulse. The client's
adult child states, "Please, do whatever you can to save them!" Which intervention is
appropriate? - ANSWER 3. Explain the client's resuscitation directive to the client's
child
2
,Clients can create a do not attempt resuscitation (DNAR) directive instructing that CPR and
other life-saving measures be withheld. With an advance directive in place, the client's
wishes should be followed, even if they conflict with the wishes of loved ones
The nurse in the cardiac intensive care unit receives report on 4 clients. Which client should
the nurse assess first? - ANSWER 2. Client who underwent coronary artery stent
placement via femoral approach 3 hours ago and is reporting severe back pain
A client who undergoes percutaneous coronary intervention (PCI) and intracoronary stent
placement using the femoral approach is at increased risk for retroperitoneal hemorrhage.
Administration of antithrombotic drugs before, during, and after PCI can exacerbate
potentially life-threatening bleeding from the femoral artery.
Hypotension, back pain, flank ecchymosis (eg, Grey Turner sign), hematoma formation, and
diminished distal pulses can be early signs of bleeding into the retroperitoneal space and
require immediate intervention (eg, notify health care provider, serial complete blood count,
CT scan of the abdomen)
The nurse is reviewing the medical history of a client who has sustained a right tibia/fibula
fracture from a fall. The nurse identifies which finding as most likely to hinder healing? -
ANSWER 4. Peripheral arterial disease
Bone healing depends on multiple factors, including nutrition, adequate circulation, and age.
A client with peripheral arterial disease has decreased perfusion to the extremities due to
atherosclerotic changes in the arteries. Without adequate perfusion, the bone is not
supplied with the oxygen and nutrients required for healing
Based on the nursing assessment progress notes, what is the correct staging of the client's
pressure injury? Click on the exhibit button for additional information. -
ANSWER WRONG
3
, 2. Stage 2: Stage 2 pressure injuries have partial-thickness skin loss (abrasion, blister, or
shallow crater). The skin blisters or forms an open sore, and the area around the sore may
be red and irritated. (shallow, open ulcer, red-pink wound with no sloughing and possible
intact or ruptured blister)
Stage 1: Intact skin with nonblanchable redness
Stage 2: Partial-thickness skin loss (abrasion, blister, or shallow crater) involving the dermis
or epidermis; the wound bed is red or pink and may be shiny or dry
Stage 3: Full-thickness skin loss; subcutaneous fat is visible but not tendon, muscle, or bone;
tunneling may be present
Stage 4: Full-thickness skin loss with visible tendon, muscle, or bone; slough or eschar
(scabbing, dead tissue) may be present; undermining and tunneling may be present
Pressure injuries are described as "unstageable" if the base is covered by necrotic tissue or
eschar
A client with type 1 diabetes mellitus has prescriptions for NPH insulin and regular insulin. At
0730, the client's blood glucose level is 322 mg/dL (17.9 mmol/L), and the breakfast tray has
arrived. What action should the nurse take? Click the exhibit button for additional
information. - ANSWER 4. Administer 37 units of insulin: 25 units of NPH mixed with
12 units of regular insulin in the same syringe, drawing up the regular insulin first
Intermediate-acting insulins (NPH) can be safely mixed with short-acting (regular) and rapid-
acting (eg, lispro, aspart) insulins in one syringe. Regular insulin should be drawn into the
syringe before intermediate-acting insulin to avoid cross-contaminating multidose vials
(mnemonic - RN: Regular before NPH).
To prepare the mixed dose:
Inject 25 units of air into the NPH insulin vial without inverting the vial or passing the needle
into the solution.
Inject 12 units of air into the regular insulin vial and withdraw the dose, leaving no air
bubbles.
Draw 25 units of NPH insulin, totaling 37 units in one syringe. Any overdraw of NPH into the
syringe will necessitate wasting the entire quantity.
4
has a pulse of 50/min. The nurse calls emergency services and initiates rescue breathing.
After 2 minutes of rescue breaths, the child is still not breathing and is pale with a pulse of
30/min. What is the nurse's next action? - ANSWER 1. Initiate chest compressions
Rescue breathing is performed at a rate of 1 breath every 2-3 seconds. If the pulse remains
<60/min and there are signs of poor perfusion (skin pallor), the nurse should initiate chest
compressions and reassess the pulse every 2 minutes
The charger nurse is responsible for making room assignments multiple clients. Which pari
of client assignments to a shared room is appropriate? - ANSWER 3. Client who had a
bowel resection 1 day ago and client with asthma exacerbation.
When making room assignments, it is important to remember that a client with an active or
suspected infection should not be paired with a client who has a fresh surgical wound or is
immunocompromised. A client having an asthma exacerbation does not have an infection
and is not at risk for spreading infection to a client who had a recent bowel resection
surgery.
The clinic nurse is assessing a client who is being treated for depression and suicidal
ideation. Which client statement best indicates that the client is not currently at risk for
suicide? - ANSWER 2. "I plan to attend my grandchild's graduation next month"
Clients receiving treatment for depression and suicidal ideation must be carefully monitored
for indications of increasing suicidal intent. During a client interview, the nurse should
assess:
1
,- Access to psychiatric medications
- Availability of help during a crisis (counselor, family)
- Future goals and plans
- Home and environment risks
- Overall affect and level of energy
- Possible access to weapons
Clients who articulate long-term personal goals and family milestones are less likely to
attempt death by suicide
The nurse is caring for a client who had an anterior wall myocardial infarction 2 days ago.
The telemetry technician notifies the nurse at 8:30 AM that the client is in ventricular
trigeminy. What is the nurse's priority intervention? - ANSWER 1. Administer
potassium supplement
In ventricular trigeminy, premature ventricular contractions (PVCs) occur every third
heartbeat. Myocardial injury (eg, myocardial infarction) predisposes the client to ectopy (eg,
PVCs), which increases the client's risk for lethal dysrhythmias (eg, ventricular tachycardia).
PVCs are caused and/or exacerbated by hypoxia, electrolyte imbalances, emotional stress,
stimulants, fever, and exercise.
This client's morning laboratory results show hypokalemia (potassium <3.5 mEq/L [3.5
mmol/L]); therefore, the priority is treatment of the underlying cause of the ectopy by
administering the prescribed potassium replacement (Option 1). Health care providers
(HCPs) often prescribe electrolyte replacement algorithms to clients at risk for electrolyte
imbalances (eg, myocardial injury, receiving diuretics) unless a contraindication exists (eg,
serum creatinine >1.5 mg/dL [133 µmol/L], anuric, weight <99.2 lb [45 kg]).
The nurse cares for a client with a terminal disease who created a do not attempt
resuscitation (DNAR) directive. The client stops breathing and loses their pulse. The client's
adult child states, "Please, do whatever you can to save them!" Which intervention is
appropriate? - ANSWER 3. Explain the client's resuscitation directive to the client's
child
2
,Clients can create a do not attempt resuscitation (DNAR) directive instructing that CPR and
other life-saving measures be withheld. With an advance directive in place, the client's
wishes should be followed, even if they conflict with the wishes of loved ones
The nurse in the cardiac intensive care unit receives report on 4 clients. Which client should
the nurse assess first? - ANSWER 2. Client who underwent coronary artery stent
placement via femoral approach 3 hours ago and is reporting severe back pain
A client who undergoes percutaneous coronary intervention (PCI) and intracoronary stent
placement using the femoral approach is at increased risk for retroperitoneal hemorrhage.
Administration of antithrombotic drugs before, during, and after PCI can exacerbate
potentially life-threatening bleeding from the femoral artery.
Hypotension, back pain, flank ecchymosis (eg, Grey Turner sign), hematoma formation, and
diminished distal pulses can be early signs of bleeding into the retroperitoneal space and
require immediate intervention (eg, notify health care provider, serial complete blood count,
CT scan of the abdomen)
The nurse is reviewing the medical history of a client who has sustained a right tibia/fibula
fracture from a fall. The nurse identifies which finding as most likely to hinder healing? -
ANSWER 4. Peripheral arterial disease
Bone healing depends on multiple factors, including nutrition, adequate circulation, and age.
A client with peripheral arterial disease has decreased perfusion to the extremities due to
atherosclerotic changes in the arteries. Without adequate perfusion, the bone is not
supplied with the oxygen and nutrients required for healing
Based on the nursing assessment progress notes, what is the correct staging of the client's
pressure injury? Click on the exhibit button for additional information. -
ANSWER WRONG
3
, 2. Stage 2: Stage 2 pressure injuries have partial-thickness skin loss (abrasion, blister, or
shallow crater). The skin blisters or forms an open sore, and the area around the sore may
be red and irritated. (shallow, open ulcer, red-pink wound with no sloughing and possible
intact or ruptured blister)
Stage 1: Intact skin with nonblanchable redness
Stage 2: Partial-thickness skin loss (abrasion, blister, or shallow crater) involving the dermis
or epidermis; the wound bed is red or pink and may be shiny or dry
Stage 3: Full-thickness skin loss; subcutaneous fat is visible but not tendon, muscle, or bone;
tunneling may be present
Stage 4: Full-thickness skin loss with visible tendon, muscle, or bone; slough or eschar
(scabbing, dead tissue) may be present; undermining and tunneling may be present
Pressure injuries are described as "unstageable" if the base is covered by necrotic tissue or
eschar
A client with type 1 diabetes mellitus has prescriptions for NPH insulin and regular insulin. At
0730, the client's blood glucose level is 322 mg/dL (17.9 mmol/L), and the breakfast tray has
arrived. What action should the nurse take? Click the exhibit button for additional
information. - ANSWER 4. Administer 37 units of insulin: 25 units of NPH mixed with
12 units of regular insulin in the same syringe, drawing up the regular insulin first
Intermediate-acting insulins (NPH) can be safely mixed with short-acting (regular) and rapid-
acting (eg, lispro, aspart) insulins in one syringe. Regular insulin should be drawn into the
syringe before intermediate-acting insulin to avoid cross-contaminating multidose vials
(mnemonic - RN: Regular before NPH).
To prepare the mixed dose:
Inject 25 units of air into the NPH insulin vial without inverting the vial or passing the needle
into the solution.
Inject 12 units of air into the regular insulin vial and withdraw the dose, leaving no air
bubbles.
Draw 25 units of NPH insulin, totaling 37 units in one syringe. Any overdraw of NPH into the
syringe will necessitate wasting the entire quantity.
4
