Nursing Elites

1. While eating in the hospital cafeteria, a nurse notices a toddler at a nearby table choking on a piece of food and appearing slightly blue. What is the appropriate initial action to take?

• A. Begin mouth-to-mouth resuscitation
• B. Give the child water to help with swallowing
• C. Perform 5 abdominal thrusts
• D. Call for the emergency response team

Correct answer: C

Rationale: When a toddler is choking on a piece of food and appears blue, it indicates airway obstruction. The appropriate initial action should be to perform 5 abdominal thrusts. This technique can help dislodge the obstructing object and clear the airway. Initiating mouth-to-mouth resuscitation is not recommended as the first step in a choking emergency, especially in children. Giving water may not be effective and can worsen the situation by causing further blockage. Calling the emergency response team should be considered if the abdominal thrusts are unsuccessful in clearing the airway.

2. The healthcare professional calculates the IV flow rate for a patient receiving an antibiotic. The patient is to receive 100mL of the antibiotic over 30 minutes. The IV infusion set has a drop factor of 10 drops per milliliter. How many drops per minute should the healthcare professional set the IV to deliver?

• A. 11
• B. 19
• C. 26
• D. 33

Correct answer: D

Rationale: To determine the drops per minute for the IV flow rate, you can use the formula: Drops Per Minute = (Milliliters to be infused x Drop Factor) / Time in Minutes. Substituting the given values, you get 100 mL x 10 drops/mL / 30 minutes = 33 drops per minute. Therefore, the correct answer is 33, as the healthcare professional should set the IV to deliver 33 drops per minute to infuse the antibiotic correctly. Choices A, B, and C are incorrect as they do not match the calculated drops per minute based on the provided values.

3. A nurse frequently treats patients in the 72-hour period after a stroke has occurred. The nurse would be most concerned about which of these assessment findings?

• A. INR is 3 seconds long
• B. Heart rate is 110 beats per minute
• C. Intracranial Pressure is 22 mmHg
• D. Blood pressure is 140/80

Correct answer: C

Rationale: The nurse would be most concerned about the assessment finding of an Intracranial Pressure (ICP) reading of 22 mmHg in a patient 72 hours post-stroke. Elevated ICP can indicate increased risk of edema and further brain damage. A target ICP should ideally be maintained at less than or equal to 15-20 mmHg. While the other options may also be important to monitor, an elevated ICP poses a more immediate threat to the patient's neurological status and requires prompt attention.

4. A patient's nursing diagnosis is Insomnia. The desired outcome is: "Patient will sleep for a minimum of 5 hours nightly by October 31."? On November 1, a review of the sleep data shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. What is the nurse's next action?

• A. Continue the current plan without changes.
• B. Remove this nursing diagnosis from the plan of care.
• C. Write a new nursing diagnosis that better reflects the problem.
• D. Revise the target date for outcome attainment and examine interventions.

Correct answer: D

Rationale: The correct action for the nurse in this scenario is to revise the target date for outcome attainment and reevaluate interventions. The initial desired outcome was for the patient to sleep for a minimum of 5 hours nightly by October 31. Since the patient is currently sleeping an average of 4 hours nightly and taking a 2-hour afternoon nap, the goal has not been achieved. By extending the time frame for attaining the outcome, the patient may have more time to progress towards the desired sleep duration. Additionally, examining interventions is crucial to identify any changes or adjustments that may be necessary to help the patient achieve the desired outcome. Continuing the current plan without changes is not appropriate as the goal has not been met. Removing the nursing diagnosis from the plan of care should only be considered when the problem is resolved. Writing a new nursing diagnosis is not needed as the current diagnosis of Insomnia still accurately reflects the patient's condition.

5. Which assessment finding would the nurse need to report most quickly to the health care provider regarding a patient with acute pancreatitis?

• A. Nausea and vomiting
• B. Hypotonic bowel sounds
• C. Abdominal tenderness and guarding
• D. Muscle twitching and finger numbness

Correct answer: D

Rationale: The correct answer is muscle twitching and finger numbness. These symptoms indicate hypocalcemia, which can lead to tetany if not promptly addressed with calcium gluconate administration. Nausea and vomiting, hypotonic bowel sounds, and abdominal tenderness and guarding are important findings in acute pancreatitis but do not require the same urgent intervention as hypocalcemia to prevent potential severe complications.

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