Nursing Elites

1. A client who was discharged 8 months ago with cirrhosis and ascites is admitted with anorexia and recent hemoptysis. The client is drowsy but responds to verbal stimuli. The nurse programs a blood pressure monitor to take readings every 15 minutes. Which assessment should the nurse implement first?

• A. Evaluate distal capillary refill for delayed perfusion
• B. Check the extremities for bruising and petechiae
• C. Examine the peritibial regions for pitting edema
• D. Palpate the abdomen for tenderness and rigidity

Correct answer: D

Rationale: In a client with a history of cirrhosis and ascites presenting with anorexia and recent hemoptysis, palpating the abdomen for tenderness and rigidity is crucial as it helps in identifying signs of complications related to these conditions. Assessing for abdominal tenderness and rigidity can provide valuable information about the presence of internal bleeding, ascites complications, or liver enlargement. Evaluating distal capillary refill, checking for bruising and petechiae, or examining peritibial regions for pitting edema are important assessments but are not the priority in this case, given the client's history and current symptoms.

2. Since children with attention deficit hyperactivity disorder (ADHD) take medication for long periods of time, side effects must be considered. How often should children be assessed for side effects of the drug therapy?

• A. Every 2 months
• B. Every 4 months
• C. Every 6 months
• D. Every 8 months

Correct answer: C

Rationale: Children with ADHD who are on long-term medication therapy should be assessed for side effects every 6 months. This timeframe allows healthcare providers to monitor the effects of the medication and make any necessary adjustments. Checking every 2 months (Choice A) may be too frequent and not practical for routine monitoring, while checking every 4 or 8 months (Choices B and D) may lead to missing potential side effects or delays in addressing them.

3. A client with cancer is receiving chemotherapy with a known vesicant. The client's IV has been in place for 72 hours. The nurse determines that a new IV site cannot be obtained and leaves the present IV in place. What is the greatest clinical risk related to this situation?

• A. Impaired skin integrity
• B. Fluid volume excess
• C. Acute pain and anxiety
• D. Peripheral neurovascular dysfunction

Correct answer: A

Rationale: The correct answer is A: Impaired skin integrity. In this situation, the greatest clinical risk is related to impaired skin integrity due to the potential extravasation of the vesicant. Vesicants are substances that can cause severe tissue damage if they leak into the surrounding tissues. Choices B, C, and D are not the most significant risks in this scenario. Fluid volume excess, acute pain, and peripheral neurovascular dysfunction are not directly associated with leaving the IV in place with a known vesicant for an extended period.

4. The nurse is preparing a client for surgery who was admitted to the emergency center following a motor vehicle collision. The client has an open fracture of the femur and is bleeding moderately from the bone protrusion site.

• A. Ensure the client is NPO and document the last meal.
• B. Administer pain medication as prescribed.
• C. Apply a sterile dressing to the wound site.
• D. Notify the healthcare provider of the client’s medication history.

Correct answer: D

Rationale: In this scenario, the priority action is to notify the healthcare provider of the client's medication history. This is important because understanding the client’s medication history, especially if they are taking anticoagulants or other medications that could affect bleeding and surgery, is crucial in ensuring safe management of the client's condition. Option A, ensuring the client is NPO and documenting the last meal, is important but not the priority in this situation. Administering pain medication (Option B) should only be done after ensuring the client's safety and stability. Applying a sterile dressing (Option C) is also important but not as critical as informing the healthcare provider of the medication history.

5. While assisting a female client to the toilet, the client begins to have a seizure, and the nurse eases her to the floor. The nurse calls for help and monitors the client until the seizing stops. Which intervention should the nurse implement first?

• A. Document details of the seizure activity.
• B. Observe for lacerations on the tongue.
• C. Observe for prolonged periods of apnea.
• D. Evaluate for evidence of incontinence.

Correct answer: A

Rationale: Documenting details of the seizure activity is the priority intervention as it is crucial for medical records and future care planning. This documentation can provide vital information for healthcare providers in understanding the type, duration, and characteristics of the seizure. Observing for lacerations on the tongue, prolonged periods of apnea, or evidence of incontinence are important assessments, but they come after documenting the seizure activity.

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