CPNRE Complex Care 5

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?

Accepted Answer

Notify the physician and prepare for potassium replacement

Answer

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?

Accepted Answer

Administer lactulose to decrease serum ammonia

Answer

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:

Accepted Answer

Sit the client upright and assess for a noxious stimulus below the injury

Answer

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?

Accepted Answer

Chest tube output of 250 mL in the last hour

Answer

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?

Accepted Answer

Grey Turner sign appearing on the flank

Answer

Grey Turner sign (flank ecchymosis) indicates retroperitoneal hemorrhage, a severe complication of acute pancreatitis signaling significant internal bleeding.

CPNRE - Canadian Practical Nurse Registration Examination Practice Test

CPNRE - Canadian Practical Nurse Registration Examination Practice Test

CPNRE Complex Care 5