Nursing Elites

1. A client is admitted to the medical unit during an exacerbation of systemic lupus erythematosus (SLE). It is most important to report which assessment finding to the healthcare provider?

• A. Low-grade fever.
• B. Muscle atrophy.
• C. Hematuria.
• D. Joint pain.

Correct answer: C

Rationale: Hematuria is the most important assessment finding to report to the healthcare provider in a client with SLE during an exacerbation. Hematuria indicates kidney involvement, a serious complication of SLE that requires prompt medical attention. While low-grade fever, muscle atrophy, and joint pain are symptoms that can occur in SLE, hematuria signifies potential renal damage, which is a critical concern in SLE exacerbations.

2. The cognitive impairment is classified into four levels based on the intelligence quotient (IQ). How is a child with an IQ of 45 classified?

• A. Within the normal low range
• B. Educable
• C. Trainable
• D. Severe

Correct answer: C

Rationale: A child with an IQ of 45 is classified as 'Trainable' in the context of cognitive impairment levels. This category is determined by an IQ range of 35 to 55. Choice A ('Within the normal low range') is incorrect as an IQ of 45 falls within the range associated with the 'Trainable' level, not the 'Normal low range.' Choice B ('Educable') is incorrect because this classification typically corresponds to individuals with slightly higher IQs that allow for academic progress with support. Choice D ('Severe') is incorrect as it does not align with the IQ level of 45, which falls within the 'Trainable' category.

3. In a disaster area, a nurse assesses an adult male with partial-thickness burns on his lower legs, approximately 10% of his lower body. Which color of triage tag should the nurse place on this client?

• A. Yellow.
• B. Black.
• C. Red.
• D. Green.

Correct answer: A

Rationale: A yellow triage tag should be placed on the client with partial-thickness burns covering 10% of his lower body. Yellow tags indicate delayed treatment, suitable for serious injuries that are not immediately life-threatening. Black tags are used for deceased individuals, red tags for immediate treatment of life-threatening injuries, and green tags for minor injuries.

4. A client is currently receiving an infusion labeled as 5% dextrose injection 500 ml with heparin sodium 25,000 units at 14 mL/hour per pump. A prescription is received to change the rate of the infusion to heparin 1,000 units/hour. How many ml/hour should the nurse program the infusion pump?

• A. 16 ml/hour.
• B. 18 ml/hour.
• C. 20 ml/hour.
• D. 22 ml/hour.

Correct answer: C

Rationale: To deliver 1,000 units/hour from a solution with 25,000 units in 500 ml, the rate should be set to 20 ml/hour. This is calculated by determining that the solution has 50 units/ml (25,000 units / 500 ml = 50 units/ml) and then dividing the required 1,000 units/hour by 50 units/ml, resulting in 20 ml/hour. Therefore, the nurse should program the infusion pump to deliver heparin at 20 ml/hour. Choices A, B, and D are incorrect as they do not align with the calculated rate of 20 ml/hour.

5. The nurse assesses an adult male client 24 hours following abdominal surgery and finds that his blood pressure is 98/40 mm Hg, he is tachycardic, restless, and irritable. Which action should the nurse take first?

• A. Notify the healthcare provider of the findings.
• B. Ensure that the IV is infusing at the prescribed rate.
• C. Listen to lung sounds.
• D. Check under his back for evidence of bleeding.

Correct answer: D

Rationale: In this scenario, the nurse should first check under the client for evidence of bleeding. A blood pressure of 98/40 mm Hg, along with tachycardia, restlessness, and irritability, could indicate internal hemorrhage following abdominal surgery. Checking for bleeding under the back is crucial to rule out this life-threatening complication. Notifying the healthcare provider, ensuring IV infusion, or listening to lung sounds can be important but are secondary to ruling out immediate life-threatening conditions like internal bleeding.

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