Nursing Elites

1. A client presents to the office with complaints of swelling in the legs, chills, and shortness of breath. During auscultation of the chest, a heart murmur is heard. The client's blood culture reveals a microorganism in the blood. When a microorganism is found in the blood, this condition is called

• A. Bacteremia
• B. Sepsis
• C. Septicemia
• D. Parasitic infection

Correct answer: A

Rationale: When a microorganism is found in the blood, this condition is called bacteremia, which refers to the presence of bacteria in the bloodstream, as indicated by a positive blood culture. If not appropriately treated, bacteremia can progress to septicemia, also known as sepsis. Sepsis is a severe and life-threatening response to an infection, characterized by systemic inflammation and organ dysfunction. Parasitic infections involve pathogens other than bacteria and are not directly related to the scenario described.

2. You are teaching students about how hyperosmotic agents (osmotic diuretics) are used to treat intracranial pressure. Which of the following is NOT one of the functions of hyperosmotic agents?

• A. Reduces brain metabolism and systemic blood pressure
• B. Reduces cerebral edema
• C. Dehydrates the brain
• D. Draws fluids from extravascular spaces into the plasma

Correct answer: A

Rationale: Hyperosmotic agents primarily work by reducing cerebral edema, dehydrating the brain, and drawing fluids from extravascular spaces into the plasma. However, they do not have a direct effect on reducing brain metabolism or systemic blood pressure. Therefore, the correct answer is A. Choice B is correct as hyperosmotic agents do help in reducing cerebral edema. Choice C is accurate as hyperosmotic agents dehydrate the brain. Choice D is also true as these agents draw fluids from extravascular spaces into the plasma.

3. An 8-year-old is placed in 90-90 traction for a fractured femur resulting from a motor vehicle collision. Which finding requires further action by the nurse?

• A. No bowel movement for two days
• B. Mother assists child in changing positions
• C. Weights are touching the foot of the bed
• D. Child is able to move the toes freely when tickled

Correct answer: C

Rationale: The correct answer is C. In 90-90 traction, the weights should hang freely and not touch the foot of the bed to maintain proper traction and bone alignment. Option A is not necessarily a concern as bowel movements can be influenced by various factors, including diet changes and pain medication. Option B indicates good caregiver involvement, promoting comfort and preventing complications. Option D demonstrates neurovascular function, which is a positive finding. Therefore, the weights touching the foot of the bed is the finding that requires immediate attention to ensure the effectiveness of the traction.

4. The PN determines that a client with cirrhosis is experiencing peripheral neuropathy. What action should the PN take?

• A. Protect the client's feet from injury
• B. Apply a heating pad to the affected area
• C. Keep the client's feet elevated
• D. Assess the feet and legs for jaundice

Correct answer: A

Rationale: Protecting the client's feet from injury is the most appropriate action for a client with cirrhosis experiencing peripheral neuropathy. Peripheral neuropathy can lead to a loss of sensation, making the client prone to unnoticed injuries. Applying a heating pad (Choice B) is contraindicated as it may cause burns or further damage to the affected area. Keeping the client's feet elevated (Choice C) is not directly related to managing peripheral neuropathy and may not provide significant benefit. Assessing the feet and legs for jaundice (Choice D) is important for monitoring liver function in clients with cirrhosis, but in this case, the priority is to prevent injury to the feet due to decreased sensation.

5. The PN notes that an older female client has developed a nonproductive cough and seems more confused than the previous day. Vital signs are temperature 99.8°F, pulse 94, respirations 22, and B/P 108/54. Which intervention is most important for the PN to implement?

• A. Report the findings to the charge nurse
• B. Monitor the client's temperature hourly
• C. Offer the client fluids frequently
• D. Provide care to moisten oral mucosa

Correct answer: A

Rationale: The change in the client’s condition, especially confusion and a new cough, may indicate the onset of an infection such as pneumonia, which requires immediate attention. Reporting to the charge nurse ensures prompt evaluation and intervention. Monitoring the client's temperature hourly (Choice B) could be important but not the most critical at this point. Offering the client fluids frequently (Choice C) and providing care to moisten oral mucosa (Choice D) are not the priority interventions when facing potential signs of infection and confusion in the client.

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