Nursing Elites

1. A client with a peripherally inserted central catheter (PICC) line has a fever. What client assessment is most important for the nurse to perform?

• A. Observe the PICC line site for inflammation.
• B. Encourage increasing fluid intake.
• C. Monitor blood pressure regularly.
• D. Assess skin turgor for dehydration.

Correct answer: A

Rationale: The correct answer is to observe the PICC line site for inflammation. When a client with a PICC line develops a fever, it could indicate an infection related to the catheter. Assessing the PICC line site for signs of inflammation, such as redness, warmth, swelling, or drainage, is crucial in identifying a potential infection early. Choice B is incorrect because increasing fluid intake is not directly related to assessing a PICC line for infection. Choice C is not the most appropriate assessment in this situation as monitoring blood pressure may not directly help in identifying the cause of the fever. Choice D is unrelated to the assessment of a fever in a client with a PICC line.

2. When taking a health history of a client admitted with acute pancreatitis, which client complaint should be expected?

• A. A low-grade fever and left lower abdominal pain
• B. Severe headache and sweating all the time
• C. Severe mid-epigastric pain after ingesting a heavy meal
• D. Dull, continuous, right lower quadrant pain and nausea

Correct answer: C

Rationale: The correct answer is C: 'Severe mid-epigastric pain after ingesting a heavy meal.' This symptom is characteristic of acute pancreatitis due to inflammation of the pancreas, which often presents with severe pain in the mid-epigastric region that may worsen after eating. Choices A, B, and D describe symptoms that are not typically associated with acute pancreatitis. A low-grade fever and left lower abdominal pain (Choice A) may be more indicative of other conditions like diverticulitis. Severe headache and sweating (Choice B) are commonly seen in conditions like migraines or infections. Dull, continuous, right lower quadrant pain and nausea (Choice D) could be suggestive of appendicitis rather than acute pancreatitis.

3. Several clients on a telemetry unit are scheduled for discharge in the morning, but a telemetry-monitored bed is needed immediately. The charge nurse should make arrangements to transfer which client to another medical unit? The client who is

• A. Learning to self-administer insulin injections after being diagnosed with diabetes mellitus
• B. Ambulatory following coronary artery bypass graft surgery performed six days ago.
• C. Wearing a sling immobilizer following permanent pacemaker insertion earlier that day
• D. Experiencing syncopal episodes resulting from dehydration caused by severe diarrhea

Correct answer: B

Rationale: The correct answer is B because the client who is ambulatory following coronary artery bypass graft surgery performed six days ago is stable enough for transfer compared to the other clients. Choice A should not be transferred as the client is still in the learning phase of self-administering insulin injections after being diagnosed with diabetes mellitus, requiring close monitoring. Choice C should not be transferred immediately after having a permanent pacemaker insertion as they need telemetry monitoring for any complications. Choice D should not be transferred as the client is experiencing syncopal episodes due to dehydration caused by severe diarrhea, requiring immediate intervention and close monitoring on the telemetry unit.

4. A client with type 2 diabetes mellitus is admitted for antibiotic treatment of a leg ulcer. Which signs and symptoms, indicative of hyperosmolar hyperglycemic nonketotic syndrome (HHNS), should the nurse report to the healthcare provider? (Select all that apply.)

• A. Increased heart rate
• B. Visual disturbances
• C. Presence of uremic frost
• D. Decreased mentation

Correct answer: A

Rationale: The correct signs and symptoms indicative of hyperosmolar hyperglycemic nonketotic syndrome (HHNS) include increased heart rate, visual disturbances, and decreased mentation. These symptoms are often associated with HHNS due to the high blood glucose levels. Uremic frost, a sign of advanced kidney disease, is not typically associated with HHNS. Therefore, choices B and D are incorrect. However, choice C, 'Presence of uremic frost,' is incorrect as it is not typically associated with HHNS.

5. The practical nurse (PN) is assigned to work with three registered nurses (RN) who are caring for neurologically compromised clients. The client with which change in status is best to assign to the PN?

• A. Diabetic ketoacidosis whose Glasgow Coma Scale score changed from 10 to 7
• B. Subdural hematoma whose blood pressure changed from 150/80 mmHg to 170/60 mmHg
• C. Myxedema coma whose blood pressure changed from 80/50 mmHg to 70/40 mmHg
• D. Viral meningitis whose temperature changed from 101° F (38.3 C) to 102° F (38.9C)

Correct answer: D

Rationale: The correct answer is D because viral meningitis with a slight increase in temperature is less acute and complex compared to the other conditions. This change in temperature does not indicate a critical or urgent situation requiring immediate attention or intervention beyond the scope of a practical nurse. Choices A, B, and C present more significant changes in health status such as a decrease in Glasgow Coma Scale score, an increase in intracranial pressure indicated by blood pressure changes, and a significant drop in blood pressure, respectively. These changes require closer monitoring and intervention by registered nurses due to the higher acuity and complexity of care needed for these conditions.

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