Prioritization
A nurse is assigned four clients. Which client should be assessed first:
1. post-op abd surgery day 1
2. stable vital signs
3. COPD with oxygen at 2 L
4. chest pain rated 8/10
What is chest pain rated 8/10.
A client taking an opioid becomes excessively sedated with respiratory depression. What medication should be anticipated?
What is Naloxone.
A client has the following ABG: pH 7.32, PaCO₂ 52 mmHg, HCO₃ 24 mEq/L. What condition is most consistent with these findings?
What is Respiratory acidosis.
(alveolar hypoventilation. the pt is not breathing deep enough or frequent enough to remove the CO2).
A client with COPD is on 4 L/min nasal cannula and becomes drowsy with rising CO₂ levels. What is the most appropriate nurse action?
What is assess respiratory status and prepare to decrease oxygen
A registered nurse is assigning tasks for a group of clients. Which assignment is most appropriate for the LPN?
A. Completing the initial admission assessment for a newly admitted client
B. Providing routine oral medications to a stable client with hypertension
C. Developing the nursing care plan for a client with diabetes
D. Teaching a client newly diagnosed with heart failure about diet changes
What is Answer: B. Providing routine oral medications to a stable client with hypertension
A client with a tracheostomy has thick secretions and is coughing frequently. Oxygen saturation is 90%. What is the nurse’s first action?
What is Suction the tracheostomy.
A client is prescribed warfarin therapy. Which lab value should the nurse monitor?
What is INR.
A client receiving loop diuretics reports muscle weakness and has U waves on ECG. Which electrolyte imbalance is most likely?
What is Hypokalemia.
A client with heart failure is prescribed furosemide and digoxin. Which lab value requires follow-up before administration?
What is K+.
(Hypokalemia increases digoxin toxicity risk)
A nurse is delegating tasks to a UAP on a medical-surgical unit. Which task is appropriate to assign?
A. Monitoring a client’s response to a new antihypertensive medication
B. Reinforcing education about diabetic diet teaching
C. Assisting a stable postoperative client with ambulation to the bathroom
D. Assessing pain level after administration of analgesics
What is Answer: C. Assisting a stable postoperative client with ambulation to the bathroom.
A nurse notices a client receiving IV potassium complaining of burning at the IV site. What is the priority action?
What is Stop the infusion.
A client with type 2 diabetes is started on first-line oral therapy. Which medication is expected and what is the most common side effect?
What is Metformin and GI upset.
A client with chronic renal failure has the following labs: K⁺ 6.2, Ca²⁺ 7.4, phosphate 6.8. Which finding requires immediate attention?
What is Potassium 6.2 mEq/L.
(life threatening)
A client with suspected pancreatitis has a serum calcium of 6.8 mg/dL and tachycardia. What complication is the nurse most concerned about?
What is Cardiac dysrhythmias.
(evere hypocalcemia affects cardiac conduction)
A provider orders 1,000 mL of 0.9% NS to infuse over 7 hours. The IV pump rounds to the nearest tenth. What is the flow rate in mL/hour?
(round to the nearest whole number)
What is 143 mL/hr?
A postoperative client suddenly becomes restless, tachycardic, and short of breath. What complication should the nurse suspect?
What is a PE.
A client taking digoxin reports nausea, visual halos, and confusion. What condition is suspected?
What is digoxin toxicity.
A client has a sodium level of 120 mEq/L and is confused but arousable. What is the priority nursing intervention?
What is initiate seizure precautions.
A client with upper GI bleeding has a G-Tube and a
J-tube. The pt is order a PPI, Jevity 1.2, and H2O flush 30ml AC & PC. The feeding is per G-Tube, and the PPI per J-tube. How should the nurse proceed?
What question the route of the PPI as it is incorrect to place in the J-tube.
(incorrect absorbtion for effectiveness. it bypasses the GI process)
A child weighs 22 lb. The ordered medication dose is 10 mg/kg/day divided into 2 equal doses. How many mg per dose should be administered? (Round to nearest tenth)
What is 50 mg per dose.
Convert weight: 22 lb ÷ 2.2 = 10 kg
Total daily dose: 10 mg/kg × 10 kg = 100 mg/day
Divide by 2 doses = 50 mg per dose
(Formula: Weight per Kg X Dose per Kg=Amount to Administer)
A nurse is caring for four clients. Which assignment should be questioned for an LPN?
A client requiring initial admission assessment
A stable diabetic receiving insulin
A client needing wound dressing change
A client receiving oral medications
What is client requiring initial admission assessment.
A client receiving heparin therapy develops sudden bleeding gums and bruising. What is the antidote?
What is Protamine sulfate.
A client with massive blood transfusion develops tingling around the mouth and prolonged QT interval. What is the cause?
What is hypocalcemia.
(Citrate in blood products binds calcium)
A client with chronic liver disease develops confusion, asterixis, and ammonia level 98 mcg/dL. What is the priority treatment?
What is Lactulose.
(lowers amonia by through bowel excretion)
A nurse must infuse 750 mL over 5 hours using tubing with a drop factor of 15 gtt/mL. What is the flow rate in gtt/min? Round to the nearest whole number.
What is 37.5 → 38 gtt/min.
*don't forget to round.*