Nursing Elites

1. A client admitted with a diagnosis of sepsis has a central venous pressure (CVP) of 15 mm Hg. What should the nurse do first?

• A. Administer a fluid bolus of 500 ml.
• B. Notify the healthcare provider immediately.
• C. Administer a diuretic.
• D. Continue to monitor the CVP.

Correct answer: B

Rationale: A CVP of 15 mm Hg is higher than normal, indicating possible fluid overload or heart failure, which needs immediate attention. Notifying the healthcare provider is crucial as they can evaluate the client's condition, order appropriate interventions, and prevent potential complications.

2. A young adult female client is seen in the emergency department for a minor injury following a motor vehicle collision. She states she is very angry at the person who hit her car. What is the best nursing response?

• A. You are lucky to be alive. Be grateful no one was killed.'
• B. I understand your car was not seriously damaged.'
• C. You are upset that this incident has brought you here.'
• D. Have you ever been in the emergency department before?'

Correct answer: C

Rationale: Validating the client's feelings can help her express and manage her emotions effectively.

3. The client has been prescribed metformin (Glucophage) for type 2 diabetes. Which instruction should the nurse include in discharge teaching?

• A. Take the medication at bedtime.
• B. Take the medication with meals.
• C. Take the medication on an empty stomach.
• D. Take the medication as needed for high blood sugar.

Correct answer: B

Rationale: The correct instruction for taking metformin (Glucophage) is with meals. This helps reduce gastrointestinal side effects and improves the medication's absorption. Taking it on an empty stomach can lead to more adverse effects, so it is essential to take it with food. Option A ('Take the medication at bedtime') is incorrect because metformin should be taken with meals to enhance its effectiveness and reduce side effects. Option C ('Take the medication on an empty stomach') is incorrect as taking metformin on an empty stomach can increase the likelihood of experiencing gastrointestinal issues. Option D ('Take the medication as needed for high blood sugar') is incorrect because metformin is typically taken regularly as prescribed, not just as needed for high blood sugar.

4. What action should the healthcare provider take to reduce the risk of vesicant extravasation in a client receiving intravenous chemotherapy?

• A. Administer an antiemetic before starting the chemotherapy.
• B. Instruct the client to drink plenty of fluids during the treatment.
• C. Keep the head of the bed elevated until the treatment is completed.
• D. Monitor the client's intravenous site hourly during the treatment.

Correct answer: D

Rationale: Monitoring the intravenous site hourly is essential to identify early signs of extravasation, such as swelling or pain, which can help prevent tissue damage. Prompt detection allows for immediate intervention, minimizing the risk of serious complications associated with vesicant extravasation.

5. A client with a severe head injury is admitted to the intensive care unit (ICU). Which finding should the nurse report to the healthcare provider immediately?

• A. Urine output of 100 mL/hour.
• B. Intracranial pressure (ICP) of 20 mm Hg.
• C. Respiratory rate of 12 breaths/minute.
• D. Mean arterial pressure (MAP) of 70 mm Hg.

Correct answer: B

Rationale: An Intracranial Pressure (ICP) of 20 mm Hg is at the upper limit of normal and may indicate increased intracranial pressure, which is a critical finding in a client with a severe head injury. Elevated ICP can lead to further brain damage and must be addressed promptly to prevent complications such as herniation. Monitoring and managing ICP are crucial in the care of patients with head injuries in the ICU.

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