Nursing Elites

1. A nurse from the maternity unit is floated to the critical care unit because of staff shortage on the evening shift. Which client would be appropriate to assign to this nurse?

• A. A client with a Dopamine drip IV with vital signs monitored every 5 minutes
• B. A client with a myocardial infarction that is free from pain and dysrhythmias
• C. A client with a tracheotomy of 24 hours in some respiratory distress
• D. A client with a pacemaker inserted this morning with intermittent capture

Correct answer: B

Rationale: In this scenario, it is more appropriate to assign a stable client, such as the one with a myocardial infarction who is free from pain and dysrhythmias, to a nurse who lacks specialized critical care experience. This client's condition is relatively stable and does not require immediate critical interventions. Choices A, C, and D involve clients with more complex and critical conditions that would be better managed by a nurse with specialized critical care training. Choice A involves a client on a Dopamine drip with frequent vital sign monitoring, Choice C has a client with a tracheotomy in respiratory distress, and Choice D describes a client with a pacemaker experiencing intermittent capture, all of which require a higher level of critical care expertise.

2. While auscultating heart sounds, the nurse hears a swishing sound. How should this sound be documented?

• A. Heart murmur.
• B. Murmur.
• C. S3 sound.
• D. S4 sound.

Correct answer: B

Rationale: The correct answer is B: 'Murmur.' A murmur is a swishing sound heard during auscultation, typically caused by turbulent blood flow through the heart or valves. Choices C and D, 'S3 sound' and 'S4 sound,' refer to specific heart sounds associated with different cardiac conditions, not the general description of a swishing sound. Choice A, 'Heart murmur,' is redundant as 'murmur' alone is sufficient to describe the swishing sound heard.

3. A client is admitted with deep vein thrombosis (DVT) and is receiving heparin therapy. What is the most important laboratory value to monitor during heparin therapy?

• A. Prothrombin time (PT)
• B. International normalized ratio (INR)
• C. Activated partial thromboplastin time (aPTT)
• D. Platelet count

Correct answer: C

Rationale: The activated partial thromboplastin time (aPTT) is the most important laboratory value to monitor during heparin therapy. It measures the intrinsic pathway of coagulation and is used to assess the effectiveness of heparin as an anticoagulant. Keeping the aPTT within the therapeutic range is crucial to prevent complications such as bleeding or clot formation. Prothrombin time (PT) and International normalized ratio (INR) are used to monitor warfarin therapy, not heparin. Platelet count is important to assess for thrombocytopenia, a potential side effect of heparin, but it is not the primary laboratory value to monitor the effectiveness of heparin therapy.

4. A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant. What action should the nurse take when finding the radiation implant in the bed?

• A. Call radiation therapy for assistance
• B. Place the implant in a lead container using long-handled forceps
• C. Leave the implant in the bed and notify the provider
• D. Dispose of the implant in the nearest sharps container

Correct answer: B

Rationale: The correct action for the nurse to take when finding the radiation implant in the bed is to use long-handled forceps to place the implant in a lead container. This procedure is crucial in reducing radiation exposure to both the patient and healthcare providers. Calling radiation therapy for assistance (Choice A) may delay the immediate need for safe handling of the implant. Leaving the implant in the bed and notifying the provider (Choice C) is unsafe and can lead to increased radiation exposure. Disposing of the implant in a sharps container (Choice D) is incorrect as the implant should be placed in a lead container, not a sharps container, to contain the radiation.

5. A client is admitted with an epidural hematoma after a skateboarding accident. How should the nurse differentiate the vascular source of intracranial bleeding?

• A. Monitor for clear fluid leakage from the nose.
• B. Assess for rapid onset of decreased level of consciousness.
• C. Check for bruising around the head and neck.
• D. Assess for changes in pupil size and reactivity.

Correct answer: B

Rationale: An epidural hematoma is characterized by a rapid onset of symptoms, including decreased level of consciousness, due to arterial bleeding, which differentiates it from other types of intracranial hemorrhage. Monitoring for clear fluid leakage from the nose (choice A) is more indicative of a basilar skull fracture and cerebrospinal fluid leak. Checking for bruising around the head and neck (choice C) is more suggestive of soft tissue injuries or facial fractures. Assessing for changes in pupil size and reactivity (choice D) is essential in evaluating traumatic brain injuries, but it is not specific to differentiating the vascular source of intracranial bleeding in an epidural hematoma.

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