Nursing Elites

1. A client with a prescription for “do not resuscitate” (DNR) begins to manifest signs of impending death. After notifying the family of the client’s status, what priority action should the nurse implement?

• A. Assess the client’s need for pain medication
• B. Document the impending signs of death
• C. Inform the nurse manager of the client’s status
• D. Communicate the client’s status to the chaplain

Correct answer: A

Rationale: Assessing the client’s need for pain medication is the priority action as it ensures comfort at the end of life. Pain management is crucial in providing comfort and dignity to clients during their final moments. Documenting impending signs of death (choice B) is important but not the immediate priority over addressing the client's comfort. Updating the nurse manager (choice C) and informing the chaplain (choice D) can follow once the client's immediate needs are met.

2. A nurse is preparing to administer an intramuscular (IM) injection to a client. What is the most appropriate site to use for an IM injection in an adult?

• A. Dorsal gluteal muscle
• B. Vastus lateralis muscle
• C. Rectus femoris muscle
• D. Deltoid muscle

Correct answer: B

Rationale: The correct answer is B: Vastus lateralis muscle. The vastus lateralis muscle is a recommended site for IM injections in adults due to its size and accessibility. The dorsal gluteal muscle is not recommended for IM injections in adults due to the proximity to major nerves and blood vessels, increasing the risk of injury. The rectus femoris muscle is not a common site for IM injections in adults. The deltoid muscle is typically used for IM injections in small-volume medications or vaccines, especially in adults.

3. To differentiate adventitious lung sounds associated with heart failure from those associated with bacterial pneumonia, what information should the nurse review?

• A. Sputum culture findings
• B. Oxygen saturation level
• C. Amount of coughing
• D. Respiratory rate

Correct answer: A

Rationale: The correct answer is A: Sputum culture findings. Reviewing sputum culture findings can provide valuable information to differentiate between bacterial pneumonia and heart failure, as the type of bacteria present in the sputum can help identify the specific infection. Oxygen saturation level (Choice B) is important for assessing oxygenation status but does not directly help in distinguishing between the two conditions based on lung sounds. The amount of coughing (Choice C) and respiratory rate (Choice D) may offer some clinical insights but are not as specific or diagnostic as sputum culture findings when differentiating between heart failure and bacterial pneumonia.

4. The nurse is completing a neurological assessment on a client with a closed head injury. The Glasgow Coma Scale (GCS) score was 13 on admission. It is now assessed at 6. What is the priority nursing intervention based on the client’s current GCS?

• A. Notify the healthcare provider of the GCS score
• B. Prepare the family for the client’s imminent death
• C. Monitor the client q1 hour for changes in the GCS score
• D. Begin cardiopulmonary resuscitation (CPR)

Correct answer: A

Rationale: A significant drop in GCS indicates a severe decline in neurological status, necessitating immediate communication with the healthcare provider. Notifying the healthcare provider allows for prompt evaluation and intervention to address the worsening condition. Choice B is incorrect because preparing the family for imminent death is premature and not supported by the information provided. Choice C is incorrect as the frequency of monitoring should be increased to every 15 minutes rather than every hour due to the significant drop in GCS. Choice D is incorrect because initiating CPR is not indicated based solely on a decreased GCS score.

5. An older client is having photocoagulation for macular degeneration. What intervention should the nurse implement during post-procedure care in the outpatient surgical unit?

• A. Apply bilateral eye patches while sleeping
• B. Use a whiteboard to communicate with the client
• C. Arrange food on the plate in a clockwise order
• D. Verbally identify oneself when entering the room

Correct answer: A

Rationale: The correct intervention is to apply bilateral eye patches while sleeping. This measure helps protect the eyes and support healing following photocoagulation for macular degeneration. Choice B is incorrect as using a whiteboard is not directly related to post-procedure care for this intervention. Choice C is incorrect as arranging food on the plate in a clockwise order is not relevant to the post-procedure care of photocoagulation. Choice D is incorrect as verbally identifying oneself when entering the room is important for communication but not specific to the post-procedure care in this scenario.

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