Nursing Elites

1. A client is admitted to the hospital with a diagnosis of septic shock. Which assessment finding indicates that the client's condition is deteriorating?

• A. Heart rate of 110 beats per minute
• B. Temperature of 99.5°F (37.5°C)
• C. Blood pressure of 88/52 mmHg
• D. Respiratory rate of 24 breaths per minute

Correct answer: C

Rationale: A blood pressure of 88/52 mmHg indicates hypotension, which is a sign of worsening septic shock. Hypotension can lead to organ failure and requires immediate intervention. Elevated heart rate (choice A), mild fever (choice B), and slightly increased respiratory rate (choice D) are common in septic shock and may not necessarily indicate a deteriorating condition as much as hypotension does.

2. A client in labor who received epidural anesthesia experiences a sudden drop in blood pressure. What action should the nurse take first?

• A. Administer oxygen via nasal cannula.
• B. Administer an intravenous fluid bolus.
• C. Prepare the client for an emergency cesarean section.
• D. Place the client in a lateral position.

Correct answer: D

Rationale: In a client experiencing a sudden drop in blood pressure after epidural anesthesia, the first action the nurse should take is to place the client in a lateral position. This position helps improve venous return and cardiac output by relieving aortocaval compression. Administering oxygen via nasal cannula may be necessary if the client shows signs of respiratory distress, but it is not the first priority in this situation. Administering an intravenous fluid bolus can help stabilize blood pressure, but repositioning the client takes precedence. Preparing the client for an emergency cesarean section is not indicated solely based on a sudden drop in blood pressure after epidural anesthesia; this step would be considered if other complications arise.

3. A client who recently had a hip replacement has a strong odor from the urine and bloody drainage on the surgical dressing. What should the nurse do first?

• A. Obtain a urine sample from the bedpan.
• B. Insert an indwelling urinary catheter.
• C. Measure the client's oral temperature.
• D. Remove dressing and assess surgical site.

Correct answer: C

Rationale: The correct answer is to measure the client's oral temperature. In this scenario, the strong odor from urine and bloody drainage on the surgical dressing are concerning signs that suggest a possible infection. Fever is a common sign of infection, so measuring the client's temperature will help confirm if an infection is present. Obtaining a urine sample, inserting an indwelling urinary catheter, or removing the dressing and assessing the surgical site are not the first priority actions when infection is suspected. These actions may be necessary later but assessing the client's temperature is the initial step to evaluate for infection.

4. When teaching a group of mothers of young children about emergency care for poisoning, which of the following statements should be included?

• A. Induce vomiting immediately after the poison ingestion
• B. Call the local Poison Control Center after inducing vomiting
• C. Call the Poison Control Center prior to any interventions
• D. Take the child to the emergency department before calling the Poison Control Center

Correct answer: C

Rationale: The correct statement to include when teaching about emergency care for poisoning is to call the Poison Control Center prior to any interventions. This is important because the Poison Control Center can provide guidance on the appropriate steps to take based on the type of poisoning, the amount ingested, and the age of the child. Inducing vomiting without professional advice can sometimes do more harm than good. Choice A is incorrect because inducing vomiting immediately is not recommended without consulting with professionals. Choice B is incorrect as it suggests calling the Poison Control Center after inducing vomiting, which is not the recommended sequence. Choice D is incorrect because it is advisable to contact the Poison Control Center first before taking the child to the emergency department.

5. A client with chronic obstructive pulmonary disease (COPD) is admitted with increasing shortness of breath. What is the nurse's priority action?

• A. Administer oxygen via nasal cannula.
• B. Reposition the client to improve breathing.
• C. Perform chest physiotherapy.
• D. Encourage the client to cough and deep breathe.

Correct answer: A

Rationale: The correct answer is A: Administer oxygen via nasal cannula. Oxygen therapy is the priority intervention for a client with COPD experiencing increasing shortness of breath. It helps improve oxygenation and relieve respiratory distress. Choice B is not the priority as oxygenation needs to be addressed first. Choice C, chest physiotherapy, may be beneficial but is not the immediate priority in this situation. Choice D, encouraging the client to cough and deep breathe, is not the priority intervention when oxygenation is compromised.

Similar Questions