Nursing Elites

1. A healthcare professional is assessing a client who has a fracture of the femur. Vital signs are obtained on admission and again in 2 hours. Which of the following changes in assessment should indicate to the healthcare professional that the client could be developing a serious complication?

• A. Increased respiratory rate from 18 to 44/min
• B. Increased oral temperature from 36.6� C (97.8� F) to 37� C (98.6� F)
• C. Increased blood pressure from 112/68 to 120/72 mm Hg
• D. Increased heart rate from 68 to 72/min

Correct answer: A

Rationale: An increased respiratory rate from 18 to 44/min is a significant change that should alert the healthcare professional to a potential serious complication. Such a drastic increase in respiratory rate may indicate respiratory distress or hypoxia, which are critical conditions requiring immediate attention. The other options show minor changes in vital signs that are within normal limits and are less likely to indicate a serious complication.

2. A client in an emergency department has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take?

• A. Raise the foot of the bed to a 90� angle
• B. Remove the dressing to inspect the wound
• C. Prepare to insert a central line
• D. Administer oxygen via nasal cannula

Correct answer: D

Rationale: In a client with a sucking chest wound, the priority is to administer oxygen via nasal cannula to improve oxygenation. The client's blood pressure, weak pulse rate, and elevated respiratory rate indicate hypovolemic shock, so increasing oxygen supply is crucial. Raising the foot of the bed, removing the dressing, or preparing to insert a central line are not immediate actions needed for a client with a sucking chest wound and signs of shock.

3. A client with tuberculosis is starting medication therapy with isoniazid, rifampin, and pyrazinamide. Which of the following instructions should the nurse include?

• A. Take isoniazid with an antacid.
• B. Provide a sputum specimen every 2 weeks to the clinic for testing.
• C. Expect your sputum cultures to be negative after 6 months of therapy.
• D. Drink at least 8 ounces of water when you take the pyrazinamide tablet.

Correct answer: D

Rationale: Pyrazinamide can cause gastrointestinal upset and is best taken with a full glass of water to minimize irritation to the stomach lining. This instruction helps reduce the risk of adverse effects associated with pyrazinamide. Options A and C are not directly related to the medication regimen for tuberculosis. While sputum testing is important, the frequency mentioned in option B is not required every two weeks.

4. A client is scheduled to have a tracheostomy placed in an hour. What action by the nurse is the priority?

• A. Administer prescribed anxiolytic medication.
• B. Ensure informed consent is on the chart.
• C. Reinforce any teaching done previously.
• D. Start the preoperative antibiotic infusion.

Correct answer: B

Rationale: The priority action for the nurse is to ensure that informed consent is on the chart. Before any surgical procedure, it is essential to have the client's informed consent documented. While administering anxiolytics, starting antibiotic infusion, and reinforcing teaching may also be necessary, obtaining informed consent takes precedence to ensure the client's understanding and agreement to proceed with the tracheostomy.

5. A client is receiving discharge teaching after a total hip replacement. Which statement by the client indicates a need for further teaching?

• A. I will avoid crossing my legs when sitting.
• B. I can sleep on my side as long as I use a pillow between my legs.
• C. I will avoid bending at the waist to pick things up.
• D. I can bend down to tie my shoes after 2 weeks.

Correct answer: D

Rationale: After a total hip replacement, clients should avoid bending at the waist past 90 degrees for at least 6 weeks to prevent dislocation of the hip prosthesis. Bending down to tie shoes involves significant hip flexion and should be avoided during the initial postoperative period to ensure proper healing and reduce the risk of complications.

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