Nursing Elites

1. A client who was involved in a motor vehicle collision is admitted with a fractured left femur that is immobilized using a fracture traction splint in preparation for an open reduction internal fixation (ORIF). The nurse determines that the client's distal pulses are diminished in the left foot. Which intervention should the nurse implement?

• A. Verify pedal pulses using a Doppler pulse device
• B. Evaluate the application of the splint to the left leg
• C. Offer ice chips and clear oral liquids
• D. Monitor the left leg for pain, pallor, paresthesia, paralysis, pressure

Correct answer: B

Rationale: Evaluating the application of the splint is the priority as it ensures it is not too tight, which could impair circulation and exacerbate the diminished pulses. Verifying pedal pulses with a Doppler pulse device may be indicated but does not directly address the immediate concern of proper splint application. Offering ice chips and clear oral liquids would not address the issue of diminished distal pulses. Monitoring the left leg for pain, pallor, paresthesia, paralysis, and pressure is important but would not directly address the cause of the diminished pulses in this scenario.

2. A client has just returned to the nursing unit after bronchoscopy. To which intervention should the nurse give priority?

• A. Assessing the client for the return of the gag reflex
• B. Administering pain medication
• C. Encouraging copious fluid intake
• D. Ambulating the client

Correct answer: A

Rationale: After bronchoscopy, the priority intervention for the nurse is to assess the client for the return of the gag reflex. This assessment is crucial to ensure the client's safety and prevent aspiration. Keeping the client on nothing-by-mouth status until the gag reflex returns is essential. Administering pain medication, encouraging fluid intake, and ambulating the client are important interventions but assessing the gag reflex takes precedence due to the risk of aspiration post-bronchoscopy.

3. The nurse is caring for a client who is receiving an IV infusion of normal saline and notices that the infusion is not flowing. The insertion site is not inflamed or swollen. What should the nurse do first?

• A. Check the tubing for kinks or obstructions.
• B. Increase the flow rate to improve the infusion.
• C. Reinsert the IV catheter in another vein.
• D. Call the physician for further instructions.

Correct answer: A

Rationale: The correct first action for the nurse to take when an IV infusion is not flowing despite a normal insertion site is to check the tubing for kinks or obstructions. This step is crucial to ensure that there are no preventable issues impeding the flow of the IV solution. Increasing the flow rate without addressing potential obstructions could lead to complications such as infiltration. Reinserting the IV catheter in another vein should only be considered after ruling out tubing issues. Calling the physician for further instructions is not necessary at this stage as troubleshooting the tubing should be the initial intervention.

4. A nurse cares for clients with urinary incontinence. Which types of incontinence are correctly paired with their clinical manifestations? (Select all that apply.)

• A. Stress incontinence – Urine loss with physical exertion
• B. Urge incontinence – Large amount of urine with each occurrence
• C. Overflow incontinence – Constant dribbling of urine
• D. All of the above

Correct answer: D

Rationale: The correct answer is D, as all the choices are correctly paired with their clinical manifestations. Stress incontinence is characterized by urine loss with physical exertion, coughing, sneezing, or exercising. Urge incontinence presents with a sudden and strong urge to void, often accompanied by a large amount of urine released during each occurrence. Overflow incontinence occurs when the bladder is distended, leading to a constant dribbling of urine. Functional incontinence, not mentioned in the options, is the leakage of urine due to factors unrelated to a lower urinary tract disorder. Reflex incontinence, also not mentioned, is a condition resulting from abnormal detrusor contractions.

5. During a routine clinic visit, a nurse is assessing a 48-year-old client with a history of smoking. The client, who exercises regularly, reports calf pain during exercise that disappears at rest. Which of the following findings requires further evaluation?

• A. Heart rate of 57 bpm.
• B. SpO2 of 94% on room air.
• C. Blood pressure of 134/82.
• D. Ankle-brachial index of 0.65.

Correct answer: D

Rationale: An Ankle-Brachial Index of 0.65 suggests moderate arterial vascular disease in a client experiencing intermittent claudication, indicating compromised blood flow to the lower extremities during exercise. This finding requires further evaluation to assess the severity of arterial insufficiency and determine appropriate interventions. Choice A (Heart rate of 57 bpm) is within the normal range for an adult at rest and indicates good cardiovascular fitness. Choice B (SpO2 of 94% on room air) is slightly lower than the normal range but is generally acceptable in a healthy individual. Choice C (Blood pressure of 134/82) falls within the normal range and does not raise immediate concerns in this context.

Similar Questions