Nursing Elites

1. A client goes to the Emergency Department with acute respiratory distress and the following arterial blood gases (ABGs): pH 7.35, PCO2 40 mmHg, PO2 63mmHg, HCO3 23, and oxygenation saturation (SAO2) 93%. Which of the following represents the best analysis of the etiology of these ABGs?

• A. tuberculosis (TB)
• B. pneumonia
• C. pleural effusion
• D. hypoxia

Correct answer: D

Rationale: A combined low PO2 and low SAO2 indicates hypoxia. The pH, PCO2, and HCO3 are normal. ABGs are not necessarily altered in TB or pleural effusion. In pneumonia, the PO2 and PCO2 might be low because hypoxia stimulates hyperventilation, but the best analysis in this case is hypoxia due to the combination of low PO2 and low SAO2.

2. A healthcare provider is caring for a patient who has experienced burns to the right lower extremity. According to the Rule of Nines, which of the following percentages most accurately describes the severity of the injury?

• A. 36%
• B. 27%
• C. 18%
• D. 9%

Correct answer: C

Rationale: According to the Rule of Nines, the right lower extremity accounts for 18% of the total body surface area. The Rule of Nines divides the body into regions, each representing 9% or a multiple of 9%, allowing for a quick estimation of the extent of burns. In this case, the correct answer is 18% as it corresponds to the percentage allocated for each lower extremity. Choices A, B, and D are incorrect as they do not match the standard allocation for the right lower extremity in the Rule of Nines.

3. A client who is newly diagnosed with Parkinson's disease and beginning medication therapy asks the nurse, 'How soon will I see improvement?' The nurse's best response is:

• A. "That varies from client to client."?
• B. "You should discuss that with your physician."?
• C. "You should notice a difference in a few days."?
• D. "It might take several weeks before you notice improvement."?

Correct answer: D

Rationale: In the case of Parkinson's disease, improvement in symptoms may take several weeks of therapy to become noticeable. Therefore, the correct answer is to inform the client that it might take several weeks before they notice improvement. Choice A acknowledges individual variability but does not provide a specific timeframe, making it less reassuring. Choice B suggests deferring the question to the physician, which is not the most supportive response. Choice C is incorrect because improvement in Parkinson's disease symptoms typically does not occur within a few days.

4. Why must the nurse be careful not to cut through or disrupt any tears, holes, bloodstains, or dirt present on the clothing of a client who has experienced trauma?

• A. The clothing is the property of another and must be treated with care.
• B. Such care facilitates repair and salvage of the clothing.
• C. The clothing of a trauma victim is potential evidence with legal implications.
• D. Such care decreases trauma to the family members receiving the clothing.

Correct answer: C

Rationale: The correct answer is C. Trauma in any client, living or dead, has potential legal and/or forensic implications. Clothing, patterns of stains, and debris are sources of potential evidence and must be preserved. Nurses must be aware of state and local regulations that require mandatory reporting of cases of suspected child and elder abuse, accidental death, and suicide. Each Emergency Department has written policies and procedures to assist nurses and other health care providers in making appropriate reports. Physical evidence is real, tangible, or latent matter that can be visualized, measured, or analyzed. Emergency Department nurses can be called on to collect evidence. Health care facilities have policies governing the collection of forensic evidence. The chain of evidence custody must be followed to ensure the integrity and credibility of the evidence. The chain of evidence custody is the pathway that evidence follows from the time it is collected until it has served its purpose in the legal investigation of an incident. Choices A, B, and D are incorrect because they do not address the crucial aspect of preserving potential evidence with legal implications that may be present on the clothing of a trauma victim.

5. A client is admitted for observation following an unrestrained motor vehicle accident. A bystander stated that he lost consciousness for 1-2 minutes. On admission, the client's Glasgow Coma Scale (GCS) was 14. The GCS is now 12. The nurse should:

• A. Re-assess in 15 minutes
• B. Stimulate the client with a sternal rub
• C. Administer Tylenol with codeine for a headache
• D. Notify the physician

Correct answer: D

Rationale: A decrease in the Glasgow Coma Scale (GCS) score from 14 to 12 indicates a significant neurological change in the client's condition. This change can be indicative of a deterioration in the client's neurological status, possibly due to intracranial bleeding or swelling. It is crucial for the nurse to notify the physician immediately to ensure prompt evaluation and intervention. Re-assessing in 15 minutes or stimulating the client with a sternal rub are not appropriate actions in this situation as they do not address the underlying cause of the decrease in GCS. Administering Tylenol with codeine for a headache is also not recommended without further assessment and evaluation of the client's condition.

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