CPNRE Complex Care 5 — Questions and Answers
Question 1: A client with diabetic ketoacidosis (DKA) has been receiving IV insulin and fluids. The nurse notes the client's serum potassium has dropped from 5.0 to 3.1 mEq/L. What is the priority intervention?
- Continue the current insulin infusion rate
- Stop the insulin infusion until potassium is corrected
- Notify the physician and prepare for potassium replacement (Correct answer)
- Administer sodium bicarbonate to correct acidosis
Correct answer: Notify the physician and prepare for potassium replacement
Insulin drives potassium into cells; hypokalemia during DKA treatment can cause life-threatening dysrhythmias, requiring potassium replacement before continuing insulin.
Question 2: A client with cirrhosis and hepatic encephalopathy is confused and has asterixis. Which intervention is most appropriate to address the encephalopathy?
- Administer lactulose to decrease serum ammonia (Correct answer)
- Provide a high-protein diet to support liver regeneration
- Administer diuretics to reduce ascites
- Restrict all oral intake and insert an NG tube
Correct answer: Administer lactulose to decrease serum ammonia
Lactulose acidifies the colon, traps ammonia, and promotes its excretion, directly treating the elevated ammonia levels causing hepatic encephalopathy.
Question 3: A client with a spinal cord injury at C5 develops bradycardia and hypertension, with a blood pressure of 190/110 mmHg, along with pounding headache and profuse sweating above the injury level. The nurse should first:
- Administer antihypertensives as ordered
- Place the client flat and assess for urinary retention
- Sit the client upright and assess for a noxious stimulus below the injury (Correct answer)
- Apply oxygen and prepare for emergency intubation
Correct answer: Sit the client upright and assess for a noxious stimulus below the injury
These signs indicate autonomic dysreflexia; sitting the client upright to lower blood pressure and identifying/eliminating the triggering noxious stimulus (commonly bladder distension) is the priority.
Question 4: A nurse is assessing a client 24 hours post-coronary artery bypass graft (CABG). Which finding requires immediate intervention?
- Serosanguineous drainage from the sternal incision of 10 mL/hr
- Chest tube output of 250 mL in the last hour (Correct answer)
- Heart rate of 88 beats per minute in sinus rhythm
- Temperature of 37.8°C
Correct answer: Chest tube output of 250 mL in the last hour
Chest tube output greater than 200 mL/hour post-cardiac surgery indicates excessive bleeding and requires immediate physician notification to assess for cardiac tamponade or surgical hemorrhage.
Question 5: A client with acute pancreatitis has severe abdominal pain, fever of 38.9°C, and lipase of 800 U/L. Which finding would most indicate a serious complication requiring urgent escalation?
- Nausea and vomiting with inability to tolerate oral fluids
- Decreased bowel sounds on auscultation
- Grey Turner sign appearing on the flank (Correct answer)
- Blood glucose of 7.2 mmol/L
Correct answer: Grey Turner sign appearing on the flank
Grey Turner sign (flank ecchymosis) indicates retroperitoneal hemorrhage, a severe complication of acute pancreatitis signaling significant internal bleeding.
Question 6: A client is receiving heparin infusion for deep vein thrombosis. The aPTT result is 120 seconds (therapeutic range 60–100 seconds). What is the appropriate nursing action?
- Continue the current infusion rate and recheck in 6 hours
- Reduce the heparin infusion rate per protocol and notify the physician (Correct answer)
- Stop the heparin infusion and administer protamine sulfate
- Increase monitoring frequency and assess for bleeding signs
Correct answer: Reduce the heparin infusion rate per protocol and notify the physician
An aPTT above the therapeutic range indicates supratherapeutic anticoagulation; reducing the rate per protocol and notifying the physician prevents bleeding complications while maintaining anticoagulation.
Question 7: A client with heart failure has an ejection fraction of 25% and is prescribed carvedilol. The client asks why they need a beta-blocker when it can 'slow the heart down.' What is the best nursing response?
- Beta-blockers increase contractility by stimulating the sympathetic nervous system
- In heart failure, beta-blockers block chronic sympathetic overstimulation, protecting the heart and improving long-term function (Correct answer)
- Carvedilol increases heart rate to improve cardiac output in heart failure
- Beta-blockers are given to control blood pressure and reduce the risk of stroke
Correct answer: In heart failure, beta-blockers block chronic sympathetic overstimulation, protecting the heart and improving long-term function
In chronic heart failure, sustained sympathetic activation is harmful; beta-blockers reduce this neurohormonal activation, reverse cardiac remodeling, and improve ejection fraction over time.
CPNRE Complex Care 5
A client with diabetic ketoacidosis (DKA) has been receiving IV insulin and fluids.
The nurse notes the client's serum potassium has dropped from 5.0 to 3.1 mEq/L.
What is the priority intervention?