Nursing Elites

1. A client is caring for a postoperative client on the surgical unit. The client's blood pressure was 142/76 mm Hg 30 minutes ago and is now 88/50 mm Hg. What action by the nurse is best?

• A. Call the Rapid Response Team.
• B. Document and continue to monitor.
• C. Notify the primary care provider.
• D. Repeat blood pressure measurement in 15 minutes.

Correct answer: A

Rationale: In this scenario, the significant drop in blood pressure indicates a potential emergency situation. The correct action is to call the Rapid Response Team (RRT) to ensure prompt intervention and prevent further deterioration that could lead to respiratory or cardiac arrest. It is crucial to act swiftly in response to such a critical change in vital signs to provide the client with the necessary care and support.

2. A client presents to the emergency department with an acute myocardial infarction (MI) at 1500 (3:00 PM). The facility has 24-hour catheterization laboratory capabilities. To meet The Joint Commission's Core Measures set, by what time should the client have a percutaneous coronary intervention performed?

• A. 1530 (3:30 PM)
• B. 1600 (4:00 PM)
• C. 1630 (4:30 PM)
• D. 1700 (5:00 PM)

Correct answer: C

Rationale: The Joint Commission's Core Measures set for MI includes percutaneous coronary intervention within 90 minutes of the diagnosis of myocardial infarction. Since the client presented at 1500 (3:00 PM), the percutaneous coronary intervention should be performed no later than 1630 (4:30 PM), to adhere to the 90-minute timeline for optimal outcomes.

3. A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take?

• A. Check the tubing connections for leaks.
• B. Check the suction control outlet on the wall.
• C. Clamp the chest tube.
• D. Continue to monitor the client's respiratory status.

Correct answer: A

Rationale: In a closed chest drainage system, slow, steady bubbling in the suction control chamber is an expected finding, indicating proper functioning of the system. There is no immediate need for intervention as this indicates the system is working as intended. The nurse should continue to monitor the client's respiratory status for any signs of distress or changes. Checking tubing connections for leaks or clamping the chest tube are unnecessary actions based on the information provided. Checking the suction control outlet on the wall is also not indicated in this scenario.

4. During assessment, a healthcare provider is evaluating a client with chronic bronchitis. Which of the following percussion sounds should the healthcare provider expect?

• A. Dullness
• B. Resonance
• C. Tympany
• D. Flatness

Correct answer: B

Rationale: In a client with chronic bronchitis, the nurse or healthcare provider would expect to hear resonant sounds upon percussion. Resonance is the normal percussion sound heard over healthy lung tissue. The other options such as dullness, tympany, and flatness are associated with different conditions or abnormalities, not typically expected in chronic bronchitis.

5. A client had an inferior wall myocardial infarction (MI). The nurse notes the client's cardiac rhythm as shown below. What action by the nurse is most important?

• A. Assess the client's blood pressure and level of consciousness.
• B. Call the health care provider or the Rapid Response Team.
• C. Obtain a permit for an emergency temporary pacemaker insertion.
• D. Prepare to administer antidysrhythmic medication.

Correct answer: A

Rationale: The ECG strip shows sinus bradycardia, which is common in clients with an inferior wall MI. This rhythm can lead to decreased perfusion due to bradycardia and blocks. The most crucial initial action for the nurse is to assess the client's hemodynamic status, including blood pressure and level of consciousness. This assessment will help determine the immediate needs of the client. Calling the health care provider or the Rapid Response Team, obtaining a permit for a pacemaker insertion, or preparing to administer antidysrhythmic medication may be necessary based on the assessment findings, but the priority is to evaluate the client's current condition first.

Similar Questions