Nursing Elites

1. A client is admitted with a diagnosis of septic shock. Which clinical finding requires immediate intervention?

• A. Blood pressure of 90/60 mmHg
• B. Temperature of 100.4°F
• C. Heart rate of 120 beats per minute
• D. Urine output of 30 ml/hour

Correct answer: C

Rationale: In a client with septic shock, a heart rate of 120 beats per minute is a critical clinical finding that requires immediate intervention. A rapid heart rate can indicate worsening sepsis and inadequate tissue perfusion. Correcting the underlying cause of the tachycardia and stabilizing the heart rate is crucial in managing septic shock. The other options, while important, do not represent an immediate threat to the patient's condition. A blood pressure of 90/60 mmHg may be expected in septic shock, a temperature of 100.4°F is mildly elevated, and a urine output of 30 ml/hour, though decreased, may not be an immediate concern in the context of septic shock.

2. A gravida 2 para 1, at 38-weeks gestation, scheduled for a repeat cesarean section in one week, is brought to the labor and delivery unit complaining of contractions every 10 minutes. While assessing the client, the client's mother enters the labor suite and says in a loud voice, 'I've had 8 children and I know she's in labor. I want her to have her cesarean section right now!' What action should the nurse take?

• A. Tell the mother to stop speaking for the client.
• B. Notify the charge nurse of the situation.
• C. Request that the mother leave the room.
• D. Request security to remove her from the room.

Correct answer: C

Rationale: In this scenario, the most appropriate action for the nurse to take is to request that the mother leave the room. This is important to maintain a calm environment and allow the healthcare team to assess and manage the situation without interference. Option A is not the best choice as it may escalate the situation. Option B, notifying the charge nurse, could be considered after addressing the immediate need to remove the mother from the room. Option D, requesting security to remove her, is not necessary at this point and may further escalate the situation unnecessarily.

3. A male client with rheumatoid arthritis is scheduled for a procedure in the morning. The procedure cannot be completed due to early morning stiffness. Which intervention should the nurse implement?

• A. Assign a UAP to assist the client with a warm shower early in the morning.
• B. Administer anti-inflammatory medication before the procedure.
• C. Encourage the client to perform range-of-motion exercises.
• D. Reschedule the procedure for later in the day.

Correct answer: A

Rationale: A warm shower can help alleviate stiffness, allowing the client to be more comfortable and mobile before the procedure. This intervention promotes increased comfort and mobility, which may help the client proceed with the procedure later in the day. Administering anti-inflammatory medication (Choice B) may be helpful but may take time to be effective, while range-of-motion exercises (Choice C) may be challenging for the client due to stiffness. Rescheduling the procedure (Choice D) does not address the immediate need to alleviate stiffness.

4. The nurse is assessing a client with left-sided heart failure. Which assessment finding is most concerning?

• A. Jugular venous distention
• B. Peripheral edema
• C. Shortness of breath
• D. Crackles in the lungs

Correct answer: C

Rationale: Shortness of breath is the most concerning finding in a client with left-sided heart failure as it indicates worsening pulmonary congestion and impaired gas exchange. This symptom suggests that the client is experiencing significant difficulty in breathing and inadequate oxygenation, requiring immediate intervention. Jugular venous distention (Choice A) is often seen in right-sided heart failure, while peripheral edema (Choice B) and crackles in the lungs (Choice D) are common manifestations of left-sided heart failure but are not as acutely concerning as severe shortness of breath, which can rapidly progress to respiratory distress if not addressed promptly.

5. When administering ceftriaxone sodium (Rocephin) intravenously to a client, which assessment finding requires the most immediate intervention by the nurse?

• A. Stridor
• B. Nausea
• C. Headache
• D. Pruritus

Correct answer: A

Rationale: The correct answer is A: Stridor. Stridor is a high-pitched, noisy breathing sound that indicates a potential airway obstruction, which can be caused by an allergic reaction. This finding requires immediate intervention by the nurse to ensure the client's airway is patent and to prevent respiratory distress. Nausea, headache, and pruritus are potential side effects of ceftriaxone sodium but do not pose immediate life-threatening risks compared to airway obstruction indicated by stridor.

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