Nursing Elites

1. An adult male who lives alone is brought to the Emergency Department by his daughter who found him unresponsive. Initial assessment indicated that the client has minimal respiratory effort, and his pupils are fixed and dilated. At the daughter's request, the client is intubated and ventilated. Which nursing intervention has the highest priority?

• A. Notify the client's minister of his condition.
• B. Determine if the client has an executed living will.
• C. Provide the family with information about palliative care.
• D. Discuss the possibility of organ donation with the family.

Correct answer: B

Rationale: Verifying whether the client has an executed living will is crucial to ensuring that his treatment preferences are followed. In this critical situation, knowing the client's wishes regarding medical interventions is paramount. Options A, C, and D are not the highest priority as they do not directly address the immediate need to determine the client's treatment preferences.

2. The nurse is assessing a 1-year-old child with bronchiolitis caused by respiratory syncytial virus (RSV). Which assessment finding requires immediate intervention?

• A. Wheezing heard on expiration
• B. Oxygen saturation of 90%
• C. Respiratory rate of 40 breaths per minute
• D. Nasal flaring with sternal retractions

Correct answer: D

Rationale: Nasal flaring with sternal retractions indicates severe respiratory distress in a 1-year-old with bronchiolitis, requiring immediate intervention. Nasal flaring and sternal retractions are signs of increased work of breathing and decreased air movement, indicating the child is struggling to breathe. Wheezing on expiration (Choice A) is common in bronchiolitis but may not require immediate intervention. An oxygen saturation of 90% (Choice B) is low but may not be the most critical finding in this case. A respiratory rate of 40 breaths per minute (Choice C) is elevated but alone may not indicate the need for immediate intervention as much as nasal flaring and sternal retractions.

3. The nurse is preparing a 50 ml dose of 50% dextrose IV for a client with insulin shock. What is the most immediate intervention by the nurse?

• A. Dilute the dextrose in one liter of 0.9% Normal Saline solution.
• B. Mix the dextrose in a 50 ml piggyback for a total volume of 100 ml.
• C. Push the undiluted dextrose slowly through the current IV infusion.
• D. Ask the pharmacist to add the dextrose to a TPN solution.

Correct answer: C

Rationale: The correct immediate intervention by the nurse in this situation is to push the undiluted 50% dextrose slowly through the current IV infusion. This is because in cases of insulin shock, where the client has dangerously low blood sugar levels, administering 50% dextrose directly into the bloodstream helps rapidly increase blood glucose levels. Choice A is incorrect because diluting the dextrose in one liter of normal saline would delay the administration of glucose, which is needed urgently. Choice B is incorrect as mixing the dextrose in a piggyback solution would also delay the administration of the concentrated dextrose. Choice D is incorrect because adding dextrose to a TPN solution is not the immediate intervention needed to address the low blood sugar levels in a client experiencing insulin shock.

4. In a client with cirrhosis admitted with ascites and jaundice, which clinical finding requires immediate intervention?

• A. Peripheral edema
• B. Confusion and altered mental status
• C. Increased abdominal girth
• D. Yellowing of the skin

Correct answer: B

Rationale: Confusion and altered mental status in a client with cirrhosis and associated ascites and jaundice are indicative of hepatic encephalopathy, a serious complication that requires immediate intervention. This condition can progress rapidly and lead to coma if not addressed promptly. Peripheral edema (choice A) and increased abdominal girth (choice C) are common manifestations of fluid retention in cirrhosis but may not require immediate intervention unless severe. Yellowing of the skin (choice D) is a classic sign of jaundice, which is already known in this client and may not necessitate immediate intervention unless associated with other concerning symptoms.

5. The nurse is caring for a client with a chest tube in place following a pneumothorax. Which assessment finding requires immediate intervention?

• A. Oxygen saturation of 94%
• B. Crepitus around the insertion site
• C. Subcutaneous emphysema
• D. Blood pressure of 110/70 mmHg

Correct answer: C

Rationale: Subcutaneous emphysema is the assessment finding that requires immediate intervention in a client with a chest tube following a pneumothorax. Subcutaneous emphysema can indicate a pneumothorax recurrence or air leak, which can compromise respiratory function and lead to serious complications. Oxygen saturation of 94% may be concerning but does not require immediate intervention as it is still within an acceptable range. Crepitus around the insertion site is common after chest tube placement and may not always indicate a problem. A blood pressure of 110/70 mmHg is within normal limits and does not require immediate intervention in this context.

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