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After reviewing the morning laboratory findings for four clients, which client should the nurse follow up with first? Reference Range:

International Normalized Ratio [0.8 to 1.1]

Blood Glucose 74 to 106 mg/dL (4.1 to 5.9 mmol/L)]

Potassium [3.5 to 5 mEq/L (3.5 to 5 mmol/L)]

Brain Natriuretic Peptide (BNP) [less than 100 pg/mL (less than 100 ng/L)]

The brain natriuretic peptide (BNP) assay for a client with shortness of breath after a myocardial infarction (MI) increases to 1000 pg/mL (1000 ng/L).

The international normalized ratio (INR) for a client who is receiving warfarin therapy increases to 2.5.

The serum glucose level for a client receiving corticosteroids increases to 150 mg/dL (8.3 mmol/L).

The potassium level for a client scheduled for renal dialysis increases to 5 mEq/L(5 mmol/L).

Answer and Explanation

The Correct Answer is A

Choice A Reason: This client has a very high BNP level, which indicates severe heart failure and fluid overload. The nurse should follow up with this client first, as they may need urgent interventions such as oxygen therapy, diuretics, and vasodilators.

Choice B Reason: This client has an INR within the therapeutic range for warfarin therapy, which is usually between 2 and 3. The nurse should monitor this client for signs of bleeding or clotting, but they do not require immediate follow-up.

Choice C Reason: This client has a mildly elevated glucose level, which may be caused by the corticosteroids that

increase blood sugar. The nurse should check the client's blood glucose regularly and administer insulin as ordered, but they do not require immediate follow-up.

Choice D Reason: This client has a normal potassium level, which is within the reference range of 3.5 to 5 mEq/L. The nurse should ensure that the client is ready for dialysis and avoid foods high in potassium, but they do not require immediate follow-up.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Choice A Reason: Instructing UAPs to transfer all non-ambulatory clients via wheelchairs is not a good intervention, as it may expose the clients and the UAPs to smoke and fire, and cause panic and congestion in the hallways. The charge nurse should follow the RACE protocol (Rescue, Alarm, Contain, Extinguish), which means rescuing only those clients who are in immediate danger, and containing the fire by closing doors and windows.

Choice B Reason: Instructing the nursing staff to evacuate ambulatory clients to the nearest fire exits is not a good intervention, as it may also expose the clients and the staff to smoke and fire, and interfere with the fire

department's efforts. The charge nurse should follow the RACE protocol, which means evacuating only as a last resort, and only after receiving instructions from the fire department.

Choice C Reason: Shutting all doors to client rooms and telling everyone to stay in their rooms until the fire

department arrives is the best intervention, as it follows the RACE protocol, which means containing the fire by closing doors and windows, and extinguishing it if possible with a fire extinguisher. This intervention also helps protect the clients and staff from smoke inhalation and fire spread, and allows the fire department to access and control the fire.

Choice D Reason: Announcing in a calm voice that all visitors should proceed immediately to the first floor via the service elevators is not a good intervention, as it may endanger the visitors and cause more damage. The charge nurse should follow the RACE protocol, which means alarming others by activating the fire alarm system and calling 911. The charge nurse should also instruct visitors not to use elevators during a fire, as they may malfunction or trap them inside.

A. Inform the pharmacist who dispensed the medication. B. Evaluate the client for symptoms of a drug overdose. C. Report the medication error to the nursing supervisor. D. Review the medication transcription with the nurse.

Correct Answer is B

Explanation

Choice A Reason: This is not the first priority because it does not address the client's safety and well-being. The charge nurse should inform the pharmacist who dispensed the medication, but this can be done later.

Choice B Reason: This is the best action because it protects the client from harm and prevents further complications. The charge nurse should evaluate the client for symptoms of a drug overdose, such as nausea, vomiting, drowsiness, or respiratory depression, and administer antidotes or supportive measures if needed.

Choice C Reason: This is not the first priority because it does not provide immediate care to the client. The charge nurse should report the medication error to the nursing supervisor, but this can be done later.

Choice D Reason: This is not the first priority because it does not correct the mistake or prevent recurrence. The charge nurse should review the medication transcription with the nurse, but this can be done later.

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Naxlex Comprehensive Predictor Exams

A fire is reported in the kitchen on the first floor of a three-floor community hospital, and the operator notifies the charge nurse on the third floor to start evacuation procedures. Which intervention should the charge nurse implement?

Correct Answer is C

Explanation

The healthcare provider prescribes an oral medication to be given daily for 3 days. However, the medication was also given on the fourth day. Which intervention is most important for the charge nurse to implement?

Correct Answer is B

Explanation

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In assigning client care to a nurse and a practical nurse (PN), it is most important to assign which client to the nurse?

A staff nurse has been tardy for morning shift assignments for the past three days and provides no explanation for arriving late. Which approach is best for the nurse manager to use when addressing this staff member's tardiness?

Four clients are scheduled to receive IV infusions, but there are only three intravenous (IV) pumps available. Which prescribed infusion can most safely be administered without an IV infusion pump?