Nursing Elites

1. A client with a history of peptic ulcer disease arrives in the emergency department complaining of weakness and states that he vomited 'a lot of dark coffee-looking stomach contents.' The client is cool and moist to the touch. BP 90/50, HR 110, RR 20, T 98. Of the following physician orders, which will the nurse perform first?

• A. Initiate oxygen at 2 liters/nasal cannula.
• B. Start an IV of NS at 150 ml/hr
• C. Insert NG tube to low suction
• D. Attach the client to the ECG monitor

Correct answer: A

Rationale: The correct answer is to initiate oxygen at 2 liters/nasal cannula. The client is presenting signs of shock with hypotension, tachycardia, and cool, moist skin, which indicate poor tissue perfusion. Oxygen should be administered first to improve tissue oxygenation. While all interventions are important, oxygenation takes priority in the ABCs of emergency care. Starting an IV of NS, inserting an NG tube, and attaching the client to the ECG monitor are necessary interventions but should follow the priority of oxygen administration in this scenario.

2. The schizophrenic client who is admitted to the hospital for possible bowel obstruction has an NG tube and complains of pain. What should the nurse do at this time?

• A. Decrease the stimuli and observe frequently
• B. Administer the PRN sedative
• C. Call the physician immediately
• D. Administer the PRN pain medication

Correct answer: D

Rationale: In this scenario, the nurse should administer the PRN (as needed) pain medication to address the schizophrenic client's complaint of pain. It is essential to provide relief and comfort to the client experiencing pain. Option A, decreasing stimuli and observing frequently, may not address the underlying cause of pain and delay relief. Option B, administering a sedative, does not target the pain but may mask symptoms. Option C, calling the physician immediately, while important in some situations, is not the most immediate action needed to alleviate the client's pain. Therefore, the most appropriate action at this time is to administer the PRN pain medication to help alleviate the client's discomfort.

3. While assessing a patient who has undergone a recent CABG, the nurse notices a mole with irregular edges and a bluish color. What should the nurse do next?

• A. Recommend a dermatological consult to the physician.
• B. Note the location of the mole and contact the physician via telephone.
• C. Note the location of the mole and follow-up with the attending physician through the medical record and a phone call.
• D. Remove the mole with a sharp debridement technique, following approval from the charge nurse.

Correct answer: C

Rationale: In this scenario, the nurse should note the location of the mole and follow up with the attending physician through the medical record and a phone call. This action is appropriate because a mole with irregular edges and a bluish color raises concern for melanoma, a type of skin cancer. Recommending a dermatological consult (Choice A) might delay the evaluation and management of the mole. Contacting the physician via telephone (Choice B) may not provide a documented record of the observation. Removing the mole without proper evaluation (Choice D) could be dangerous and is not within the nurse's scope of practice.

4. A month after receiving a blood transfusion, an immunocompromised client develops fever, liver abnormalities, a rash, and diarrhea. The nurse should suspect this client has:

• A. no relation to the blood transfusion.
• B. graft-versus-host disease (GVHD).
• C. myelosuppression.
• D. an allergic reaction to a recent medication.

Correct answer: B

Rationale: In this scenario, the symptoms of fever, liver abnormalities, rash, and diarrhea in an immunocompromised client a month after a blood transfusion are indicative of graft-versus-host disease (GVHD). GVHD occurs when white blood cells in donor blood attack the tissues of an immunocompromised recipient. This process can manifest within a month of the transfusion. While choices 1 and 4 are plausible, it is crucial for the nurse to consider the possibility of GVHD in immunocompromised transfusion recipients due to the significant risk. Myelosuppression, choice C, typically presents with decreased blood cell counts and is not consistent with the symptoms described. An allergic reaction to medication, choice D, would present with different manifestations such as itching, hives, or anaphylaxis, which are not described in the scenario.

5. A pregnant Asian client who is experiencing morning sickness wants to take ginger to relieve the nausea. Which of the following responses by the nurse is appropriate?

• A. "I will call your physician to see if we can start some ginger."?
• B. "We don't use home remedies in this clinic."?
• C. "Herbs are not as effective as regular medicines."?
• D. "Just eat some dry crackers instead."?

Correct answer: A

Rationale: The correct response is to offer to consult with the physician regarding the use of ginger, showing cultural sensitivity. Ginger is known to help relieve nausea, especially in pregnancy. Choice A is the correct answer as it respects the client's preference for a home remedy and involves the physician in the decision-making process. Choice B dismisses the client's preference for a home remedy without exploring its potential benefits. Choice C makes a generalized statement discrediting the effectiveness of herbs, which is not evidence-based and disregards the client's beliefs. Choice D offers an alternative without addressing the client's specific request, failing to acknowledge the client's autonomy and cultural background.

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