Sugar, Sugar
A client with type 1 diabetes has a blood glucose of 348 mg/dL, positive urine ketones, Kussmaul respirations, and fruity-smelling breath. Which provider order should the nurse implement first?
What is initiate IV normal saline? (Fluids are always first before insulin.)
Which client should the nurse recommend receive annual low-dose CT screening?
A. 48-year-old with asthma
B. 60-year-old with a 25-pack-year smoking history
C. 35-year-old with COPD
D. 72-year-old who never smoked
What is the 60-year-old with a 25-pack-year history?
A nurse is changing a central venous catheter dressing. While applying the new sterile dressing, the nurse's sterile glove touches the client's shoulder. What is the nurse's priority action?
A. Continue because the glove did not touch the insertion site.
B. Clean the glove with chlorhexidine.
C. Remove the contaminated glove and don a new sterile glove.
D. Ask another nurse to finish the dressing change.
What is replace the contaminated glove?
A client suddenly becomes restless with an oxygen saturation of 84%. What is the nurse's priority?
What is administer oxygen?
A client develops muscle weakness, peaked T waves, and a potassium of 6.8 mEq/L. Which medication should the nurse anticipate?
What is kayexalate or IV insulin with dextrose?
A client with DKA has a potassium level of 3.1 mEq/L. Which intervention should the nurse question?
What is administer IV regular insulin immediately? (Potassium must be corrected first because insulin lowers serum potassium.)
A client is receiving brachytherapy for cervical cancer. Which nursing action is appropriate?
What is limit time in the room and maximize distance from the radiation source?
During tracheostomy care, the client suddenly coughs and the tracheostomy tube becomes dislodged. The client is breathing with moderate distress. What should the nurse do first?
A. Call the rapid response team.
B. Attempt to reinsert the tracheostomy tube using the obturator.
C. Cover the stoma with sterile gauze.
D. Begin bag-mask ventilation over the mouth.
What is attempt to reinsert the tracheostomy tube using the obturator
Which assessment finding requires immediate intervention after a thoracentesis?
What is tracheal deviation with absent breath sounds?
Which electrolyte imbalance places the patient at greatest risk for torsades de pointes?
What is hypomagnesemia?
A patient taking metformin is scheduled for a CT scan with IV contrast tomorrow morning. Which nursing action is most appropriate?
What is hold metformin before the procedure and for 48 hours afterward?
Which assessment finding is most concerning for metastatic disease?
A. Localized breast tenderness
B. Enlarged regional lymph nodes
C. Positive M1 staging
D. Benign biopsy
What is M1 staging?
The nurse is preparing to change a central line dressing. Which action requires intervention by the charge nurse?
A. Wearing a mask during the procedure.
B. Cleaning the site with chlorhexidine using friction for 30 seconds.
C. Blowing on the site to help the chlorhexidine dry faster.
D. Allowing the site to air dry completely before applying the dressing.
What is blowing on the site to help the chlorhexidine dry faster.
The nurse auscultates absent breath sounds over the left lung after central line insertion. Which complication is suspected?
What is pneumothorax?
A patient has numbness around the mouth, positive Chvostek's sign, and muscle spasms. Which electrolyte imbalance does the nurse suspect?
What is hypocalcemia?
A client reports awakening every morning with blood glucose levels around 260 mg/dL. A 2 a.m. glucose is 48 mg/dL. Which phenomenon does the nurse suspect?
What is the Somogyi effect?
A client states they have had a hoarse voice and sore throat for six weeks and difficulty swallowing. Which nursing response is most appropriate?
What is recommend immediate medical evaluation for possible cancer?
The nurse is suctioning a client with a tracheostomy. The client's heart rate suddenly drops from 88 to 42 bpm. What is the nurse's priority action?
Withdraw the catheter and administer oxygen.
A COPD patient has an ABG of pH 7.36, PaCO₂ 58, HCO₃ 33. How should the nurse interpret these results?
What is compensated respiratory acidosis?
A patient receiving total parenteral nutrition develops profound muscle weakness and respiratory failure. Which electrolyte should the nurse suspect is critically low?
What is phosphorus?
The nurse is caring for a client receiving an insulin infusion for DKA. Which laboratory value requires immediate intervention?
A. Sodium 135 mEq/L
B. Potassium 2.9 mEq/L
C. Magnesium 1.8 mg/dL
D. Glucose 210 mg/dL
What is Potassium 2.9 mEq/L?
The nurse reviews pathology results showing cells with large irregular nuclei, abnormal chromosome numbers, and invasion into surrounding tissue. Which conclusion is most appropriate?
What is malignant neoplasm?
A nurse enters a client's room and finds the following:
A. Central venous catheter dressing is damp and lifting at one corner.
B. The client has a temperature of 38.8°C (101.8°F).
C. Blood cultures have been ordered.
D. IV antibiotics are due in 30 minutes.
Which action should the nurse perform first?
What is obtain the ordered blood cultures.
Which patient should the nurse assess first?
A. COPD with SpO₂ 90%
B. Asthma with expiratory wheezing
C. Post-op patient with sudden dyspnea and unilateral absent breath sounds
D. Pneumonia with crackles
What is the post-op patient with sudden dyspnea?
The nurse receives four laboratory results. Which patient should be assessed first?
A. Calcium 7.8 mg/dL
B. Magnesium 1.5 mg/dL
C. Potassium 6.7 mEq/L with peaked T waves
D. Phosphorus 2.2 mg/dL
What is the patient with potassium 6.7 mEq/L and ECG changes?