Nursing Elites

1. A client presents to the emergency department with an acute myocardial infarction (MI) at 1500 (3:00 PM). The facility has 24-hour catheterization laboratory capabilities. To meet The Joint Commission's Core Measures set, by what time should the client have a percutaneous coronary intervention performed?

• A. 1530 (3:30 PM)
• B. 1600 (4:00 PM)
• C. 1630 (4:30 PM)
• D. 1700 (5:00 PM)

Correct answer: C

Rationale: The Joint Commission's Core Measures set for MI includes percutaneous coronary intervention within 90 minutes of the diagnosis of myocardial infarction. Since the client presented at 1500 (3:00 PM), the percutaneous coronary intervention should be performed no later than 1630 (4:30 PM), to adhere to the 90-minute timeline for optimal outcomes.

2. A client in an emergency department has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take?

• A. Raise the foot of the bed to a 90° angle
• B. Remove the dressing to inspect the wound
• C. Prepare to insert a central line
• D. Administer oxygen via nasal cannula

Correct answer: Administer oxygen via nasal cannula

Rationale: In a client with a sucking chest wound, the priority is to administer oxygen via nasal cannula to improve oxygenation. The client's blood pressure, weak pulse rate, and elevated respiratory rate indicate hypovolemic shock, so increasing oxygen supply is crucial. Raising the foot of the bed, removing the dressing, or preparing to insert a central line are not immediate actions needed for a client with a sucking chest wound and signs of shock.

3. A client's arterial blood gas results show a pH of 7.3 and a PaCO2 of 50 mm Hg. The client is experiencing which of the following acid-base imbalances?

• A. Metabolic acidosis
• B. Metabolic alkalosis
• C. Respiratory acidosis
• D. Respiratory alkalosis

Correct answer: C: Respiratory acidosis

Rationale: In respiratory acidosis, there is an excess of carbon dioxide (PaCO2 > 45 mm Hg) leading to a decrease in pH (<7.35). The given values of a pH of 7.3 and PaCO2 of 50 mm Hg indicate respiratory acidosis. Metabolic acidosis involves a primary decrease in bicarbonate levels with a compensatory decrease in PaCO2 to maintain balance. Metabolic alkalosis is characterized by elevated pH and bicarbonate levels. Respiratory alkalosis is marked by low PaCO2 and increased pH levels.

4. A client is in the immediate postoperative period following a partial laryngectomy. Which of the following parameters should the nurse assess first?

• A. Pain severity
• B. Wound drainage
• C. Tissue integrity
• D. Airway patency

Correct answer: Airway patency

Rationale: In a client following a partial laryngectomy, the priority assessment is always airway patency. This is crucial to ensure that the client can breathe adequately and prevent any complications related to airway obstruction. Monitoring airway patency takes precedence over other assessments such as pain severity, wound drainage, and tissue integrity. Any compromise in airway patency requires immediate intervention to maintain the client's respiratory function and safety.

5. A client had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings?

• A. Poor impulse control
• B. Inability to discriminate words and letters
• C. Deficits in the right visual field
• D. Motor retardation

Correct answer: Poor impulse control

Rationale: A stroke affecting the right cerebral hemisphere can lead to poor impulse control due to the involvement of this area in regulating behavior and inhibiting impulses. Deficits in the right visual field are associated with stroke affecting the left cerebral hemisphere. Inability to discriminate words and letters may be seen in left cerebral hemisphere strokes. Motor retardation may be observed with strokes affecting motor areas in either hemisphere but is not the most specific finding related to a right cerebral hemisphere stroke.

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