Nursing Elites

1. An adult suffered burns to the face and chest resulting from a grease fire. On admission, the client was intubated, and a 2-liter bolus of normal saline was administered IV. Currently, the normal saline is infusing at 250 ml/hour. The client’s heart rate is 120 beats/minute, blood pressure is 90/50 mmHg, respirations are 12 breaths/minute over the ventilated 12 breaths for a total of 24 breaths/minute, and the central venous pressure (CVP) is 4 mm H2O. Which intervention should the nurse implement?

• A. Increase the rate of normal saline infusion
• B. Infuse an additional bolus of normal saline
• C. Lower the head of the bed to a recumbent position
• D. Bring a tracheostomy tray to the bedside

Correct answer: B

Rationale: The correct intervention is to infuse an additional bolus of normal saline. The client's presentation with a heart rate of 120 beats/minute, hypotensive blood pressure of 90/50 mmHg, and low CVP of 4 mm H2O indicates hypovolemic shock. Administering more normal saline can help in restoring intravascular volume and improving perfusion. Increasing the rate of normal saline infusion (Choice A) is not the best choice as it may lead to fluid overload. Lowering the head of the bed to a recumbent position (Choice C) could worsen hypotension by reducing venous return. Bringing a tracheostomy tray to the bedside (Choice D) is not a priority at this time as the client is already intubated, and the immediate concern is addressing the hypovolemia.

2. The parents of a 6-year-old child recently diagnosed with Duchenne muscular dystrophy tell the nurse that their child wants to continue attending swimming classes. How should the nurse respond?

• A. Encourage the parents to allow the child to continue attending swimming lessons with supervision
• B. Suggest that the child be encouraged to participate in a team sport to promote socialization
• C. Explain that their child is not mature enough to understand the risks associated with swimming
• D. Provide a list of alternative activities that are less likely to cause the child to experience fatigue

Correct answer: A

Rationale: Encouraging the parents to allow the child to continue attending swimming lessons with supervision is the most appropriate response. Swimming can be beneficial for the child, providing both exercise and enjoyment. Supervision can help manage any risks associated with swimming. Choice B is incorrect because the child's preference for swimming should be respected, and swimming can still offer socialization opportunities. Choice C is incorrect as it undermines the child's capability to understand the situation. Choice D is less appropriate as it does not address the child's interest in swimming and may limit beneficial physical activity.

3. The nurse has explained safety precautions and infant care to a primigravida mother and observes the mother as she gives care to her newborn during the first two days of rooming-in. Which action indicates the mother understands the instruction?

• A. Aspirates the newborn’s nares using a syringe
• B. Applies a dressing to the cord after the newborn’s bath
• C. Breastfeeds the infant every hour during the night
• D. Positions the infant supine in the crib to sleep

Correct answer: D

Rationale: Positioning the infant supine in the crib to sleep is the correct action that indicates the mother understands the instruction. This position is recommended to reduce the risk of Sudden Infant Death Syndrome (SIDS). Choice A is incorrect as it is not a routine or recommended practice to aspirate the newborn’s nares using a syringe without a specific medical indication. Choice B is incorrect because applying a dressing to the cord after the newborn's bath is not a standard care practice. Choice C is incorrect because breastfeeding every hour during the night is excessive and not a recommended feeding schedule for a newborn.

4. In preparing a care plan for a client admitted with a diagnosis of Guillain-Barre syndrome, which nursing problem has the highest priority?

• A. Ineffective coping related to uncertainty of disease progression
• B. Imbalanced nutrition: less than body requirements related to impaired swallowing reflex
• C. Ineffective breathing pattern related to ascending paralysis
• D. Impaired physical mobility related to asymmetrical descending paralysis

Correct answer: C

Rationale: Ineffective breathing pattern is the highest priority nursing problem for a client with Guillain-Barre syndrome due to the potential risk of respiratory failure. As the paralysis ascends, it can affect the muscles needed for breathing, leading to respiratory compromise. Addressing this problem promptly is crucial to prevent respiratory distress and failure. Choices A, B, and D are also important nursing problems in Guillain-Barre syndrome, but ensuring effective breathing takes precedence over coping, nutrition, and mobility due to the immediate threat it poses to the client's life.

5. The unlicensed assistive personnel (UAP) reports that a client’s blood pressure cannot be measured because the client has casts on both arms and is unable to be turned to the prone position for blood pressure measurement in the legs. What action should the nurse implement?

• A. Advise the UAP to document the last blood pressure obtained on the client's graphic sheet
• B. Estimate the blood pressure by assessing the pulse volume of the client’s radial pulses
• C. Demonstrate how to palpate the popliteal pulse with the client supine and the knee flexed
• D. Document why the blood pressure cannot be accurately measured at the present time

Correct answer: D

Rationale: When a client cannot have their blood pressure measured due to specific circumstances such as casts on both arms, the nurse should document the reason why the blood pressure cannot be obtained accurately. This documentation is crucial for maintaining a clear record of the client's condition and for continuity of care. Advising the UAP to document the last blood pressure obtained (Choice A) does not address the current inability to measure the blood pressure. Estimating the blood pressure by assessing the pulse volume of radial pulses (Choice B) is not a reliable method for obtaining accurate blood pressure readings. Demonstrating how to palpate the popliteal pulse (Choice C) is irrelevant in this situation as it does not provide a solution for accurately measuring the blood pressure.

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