Nursing Elites

1. After 2 days of treatment for dehydration, a child continues to vomit and have diarrhea. Normal saline is infusing, and the child’s urine output is 50ml/hour. During morning assessment, the nurse determines that the child is lethargic and difficult to arouse. Which action should the nurse implement?

• A. Perform a finger stick glucose test
• B. Increase the IV fluid flow rate
• C. Review 24-hour intake and output
• D. Obtain arterial blood gases

Correct answer: A

Rationale: Lethargy and difficulty arousing may indicate hypoglycemia, which should be assessed before other actions. Performing a finger stick glucose test is crucial to evaluate the child's blood sugar levels and address hypoglycemia promptly. Increasing the IV fluid flow rate is not indicated without knowing the glucose status. Reviewing 24-hour intake and output is important but not the priority when lethargy and difficulty arousing are present. Obtaining arterial blood gases is not the primary assessment needed in this situation.

2. A client with leukemia who is receiving myelosuppressive chemotherapy has a platelet count of 25,000/mm3. Which intervention is most important for the nurse to include in this client’s plan of care?

• A. Monitor for signs of activity intolerance
• B. Require visitors to wear respiratory masks
• C. Assess urine and stool for occult blood
• D. Obtain client’s temperature q4 hours

Correct answer: C

Rationale: The correct answer is to assess urine and stool for occult blood. With a low platelet count, there is an increased risk of bleeding. Monitoring for occult blood is essential to detect any signs of internal bleeding. Choices A, B, and D are not the priority interventions in this situation. While monitoring for signs of activity intolerance, requiring visitors to wear respiratory masks, and obtaining the client's temperature are important aspects of care, they are not as critical as assessing for occult blood in a client with a low platelet count.

3. Which type of wound would most likely require immediate intervention by the healthcare provider?

• A. Laceration
• B. Abrasion
• C. Contusion
• D. Ulceration

Correct answer: A

Rationale: A laceration would most likely require immediate intervention by the healthcare provider due to its deeper tissue damage, significant bleeding, and higher risk of infection compared to abrasions, contusions, and ulcerations. Lacerations often need prompt attention to control bleeding, clean the wound, and reduce the risk of infection. Abrasions are superficial wounds that usually do not require urgent attention as they tend to heal well on their own with basic wound care. Contusions are bruises that typically resolve on their own without immediate intervention. Ulcerations are open sores that may require intervention but not necessarily immediate action unless complicated by infection or other issues.

4. The client demonstrates an understanding of sliding scale insulin administration instructions by performing the procedure in which order?

• A. Obtain blood glucose level
• B. Verify the insulin prescription
• C. Draw insulin into insulin syringe
• D. Cleanse the selected site

Correct answer: A

Rationale: The correct order for the client to perform the procedure is to first obtain the blood glucose level. This step is crucial as it helps determine the appropriate dose of insulin based on the sliding scale. Verifying the insulin prescription, drawing insulin into the syringe, and cleansing the selected site are important steps in the process but should follow after obtaining the blood glucose level. Therefore, options B, C, and D are incorrect in terms of the initial steps required for sliding scale insulin administration.

5. A male client admitted three days ago with respiratory failure is intubated and receiving 40% oxygen per facemask. Currently, his temperature is 99°F, capillary refill is less than 4 seconds, and respiratory effort is within normal limits. What outcome should the nurse evaluate to measure for successful extubation?

• A. Exhibits adequate tissue perfusion
• B. Remains free of injury
• C. Remains free of infection
• D. Maintains effective breathing pattern

Correct answer: D

Rationale: Successful extubation is primarily measured by the client's ability to maintain an effective breathing pattern. This indicates that the client can adequately oxygenate and ventilate without the need for artificial airway support. Choices A, B, and C are important aspects of patient care but are not the primary outcomes to evaluate for successful extubation. Adequate tissue perfusion, freedom from injury, and prevention of infection are ongoing goals during the client's hospitalization but are not the immediate focus when considering extubation.

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