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Questions 164

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Extract:

Laboratory reference ranges
Potassium3.5-5.0 mEq/L(3.5-5.0 mmol/L)
INRNormal: 0.8-1.1Therapeutic: 1.5-4.0


Question 1 of 5

The nurse recognizes which of the following factors as possibly contributing to a sentinel event?

Correct Answer: A

Rationale: Administering warfarin with an INR of 6.0 (therapeutic range 2.0-3.0) risks severe bleeding, a sentinel event. Flumazenil is appropriate for lorazepam overdose, nitroprusside for hypertensive crisis, and insulin/dextrose for hyperkalemia are correct interventions.

Extract:


Question 2 of 5

An 80-year-old woman has been hospitalized for three days with pneumonia. She is now able to sit in a chair for the first time. How should the nurse plan care for today?

Correct Answer: C

Rationale: A bed bath conserves energy, and later chair transfer allows bed-making, optimizing rest and mobility for a recovering pneumonia patient.

Question 3 of 5

The nurse is caring for assigned clients. The nurse should first check the client with

Correct Answer: A

Rationale: Severe pain (9/10) in sickle cell disease indicates a possible vaso-occlusive crisis, a medical emergency requiring immediate assessment. Fever, tachycardia, and hyperglycemia are less urgent.

Question 4 of 5

The nurse is suctioning an adult's tracheostomy tube. What action is essential before starting to suction the client?

Correct Answer: B

Rationale: Pre-oxygenation with high oxygen levels prevents hypoxia during tracheostomy suctioning, critical for patient safety, unlike water, consents, or communication aids.

Question 5 of 5

A client is admitted with diabetic ketoacidosis (DKA). Which laboratory finding requires immediate intervention by the nurse?

Correct Answer: C

Rationale: This high hematocrit is indicative of severe dehydration which requires priority attention in diabetic ketoacidosis. Without sufficient hydration, all systems of the body are at risk for hypoxia from a lack of or sluggish circulation.

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