Nursing Elites

1. A client is admitted with a diagnosis of sepsis. Which assessment finding is most concerning to the nurse?

• A. Temperature of 101.5°F
• B. Heart rate of 110 beats per minute
• C. Respiratory rate of 24 breaths per minute
• D. Blood pressure of 90/60 mmHg

Correct answer: D

Rationale: A blood pressure of 90/60 mmHg in a client with sepsis is concerning for septic shock, a life-threatening condition that requires immediate intervention. Hypotension is a severe manifestation of sepsis that can lead to poor tissue perfusion and organ failure. While the other assessment findings such as an elevated temperature, increased heart rate, and respiratory rate are also common in sepsis, hypotension is particularly alarming as it indicates a critical state of shock and necessitates urgent medical attention.

2. A client with chronic obstructive pulmonary disease (COPD) is admitted with an exacerbation. Which clinical finding requires immediate intervention?

• A. Oxygen saturation of 90%
• B. Respiratory rate of 24 breaths per minute
• C. Use of accessory muscles
• D. Inspiratory crackles

Correct answer: C

Rationale: The correct answer is C. The use of accessory muscles in a client with COPD indicates increased work of breathing and may signal respiratory failure, requiring immediate intervention. This finding suggests that the patient is struggling to breathe effectively. Oxygen saturation of 90% is low but not critically low, while a respiratory rate of 24 breaths per minute is slightly elevated but not as concerning as the increased work of breathing indicated by the use of accessory muscles. Inspiratory crackles may be present in COPD due to underlying conditions like pneumonia but do not require immediate intervention as the use of accessory muscles does.

3. The nurse is caring for a client who is 2 days postoperative following abdominal surgery. The client reports pain at the incision site and a small amount of purulent drainage is noted. What is the most appropriate nursing action?

• A. Apply a sterile dressing to the incision.
• B. Reinforce the dressing and document the findings.
• C. Remove the dressing and assess the incision site.
• D. Notify the healthcare provider.

Correct answer: D

Rationale: The correct answer is to notify the healthcare provider. Purulent drainage at the incision site is concerning as it may indicate an infection. The healthcare provider needs to be informed promptly to initiate appropriate treatment. Applying a sterile dressing (Choice A) may not address the underlying issue of infection. Reinforcing the dressing and documenting findings (Choice B) is important but should be preceded by notifying the healthcare provider. Removing the dressing and assessing the incision site (Choice C) may disturb the area and should be done under the guidance of the healthcare provider.

4. A male client is admitted with a bowel obstruction and intractable vomiting for the last several hours despite the use of antiemetics. Which intervention should the nurse implement first?

• A. Infuse 0.9% sodium chloride 500 ml bolus
• B. Administer an antiemetic intravenously
• C. Insert a nasogastric tube
• D. Prepare the client for surgery

Correct answer: A

Rationale: The correct first intervention for a male client with a bowel obstruction and intractable vomiting is to infuse 0.9% sodium chloride 500 ml bolus. This intervention is crucial to address the risk of hypovolemia due to excessive vomiting. Administering intravenous fluids will help prevent dehydration, maintain blood pressure, and stabilize the client's condition. Choice B, administering an antiemetic intravenously, may not be effective as the client has already been unresponsive to antiemetics orally. Choice C, inserting a nasogastric tube, may be necessary but is not the priority in this situation. Choice D, preparing the client for surgery, should only be considered after stabilizing the client's fluid and electrolyte balance.

5. While a child is hospitalized with acute glomerulonephritis, the parents ask why blood pressure readings are taken so often. Which response by the nurse is most accurate?

• A. Elevated blood pressure must be anticipated and identified quickly
• B. Frequent monitoring helps ensure the medication is effective
• C. It is standard protocol for all hospitalized children
• D. We need to monitor for any potential kidney damage

Correct answer: A

Rationale: The correct answer is A: 'Elevated blood pressure must be anticipated and identified quickly.' Acute glomerulonephritis can lead to significant hypertension, making it crucial to monitor blood pressure frequently to promptly identify any elevation. Choice B is incorrect because while monitoring can help assess medication effectiveness, the primary reason for frequent blood pressure checks in this case is to detect elevated blood pressure. Choice C is incorrect as not all hospitalized children require such frequent blood pressure monitoring. Choice D is incorrect as the primary reason for monitoring blood pressure is to detect hypertension, rather than solely focusing on potential kidney damage.

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