Nursing Elites

1. An unlicensed assistive personnel (UAP) reports a weak pulse of 44 beats per minute in a client. What action should the charge nurse implement?

• A. Have the UAP recheck the pulse and report back.
• B. Have a licensed practical nurse (LPN) assess the client for apical-radial pulse deficit.
• C. Call the healthcare provider for further instructions.
• D. Immediately call the healthcare provider and prepare for transfer to critical care.

Correct answer: B

Rationale: The correct action is to have a licensed practical nurse (LPN) assess the client for an apical-radial pulse deficit. This assessment can provide further information about the client’s cardiovascular status and help determine if further intervention is necessary. Having the UAP recheck the pulse may delay appropriate assessment and intervention. Calling the healthcare provider for further instructions may not be necessary at this point unless the LPN assessment indicates a need for it. Immediately transferring the client to critical care without further assessment is not warranted based solely on the initial report of a weak pulse.

2. A client is receiving external beam radiation to the mediastinum for treatment of bronchial cancer. Which of the following should take priority in planning care?

• A. Esophagitis
• B. Leukopenia
• C. Fatigue
• D. Skin irritation

Correct answer: B

Rationale: The correct answer is B: Leukopenia. Leukopenia, or a low white blood cell count, is a critical concern in clients undergoing radiation therapy due to the increased risk of infection. While esophagitis, fatigue, and skin irritation are also potential side effects of radiation therapy, leukopenia poses a higher risk as it compromises the body's ability to fight infections effectively.

3. When assessing a recently delivered multigravida client, the nurse finds that her vaginal bleeding is more than expected. Which factor in this client's history is related to this finding?

• A. The client delivered a large baby
• B. She is a gravida 6, para 5
• C. The client had a cesarean delivery
• D. The client had a prolonged labor

Correct answer: B

Rationale: A client with a higher gravida and para count is at greater risk for uterine atony, which can lead to postpartum hemorrhage. The uterus may be less effective at contracting after multiple pregnancies, causing increased vaginal bleeding. Choices A, C, and D are incorrect because delivering a large baby, having a cesarean delivery, or experiencing prolonged labor do not directly correlate with an increased risk of postpartum hemorrhage in a multigravida client as compared to the gravida and para count.

4. A male client reports numbness and tingling in his fingers and around his mouth. What laboratory value should the nurse review?

• A. Capillary glucose.
• B. Serum calcium.
• C. Urine specific gravity.
• D. White blood cell count.

Correct answer: B

Rationale: The correct answer is B, Serum calcium. Numbness and tingling in the fingers and around the mouth are indicative of hypocalcemia, a condition characterized by low calcium levels in the blood. Reviewing the client's serum calcium levels is crucial in this situation to assess for hypocalcemia. Choice A, Capillary glucose, is incorrect because symptoms described are not typically associated with glucose abnormalities. Choice C, Urine specific gravity, and Choice D, White blood cell count, are unrelated to the symptoms presented and are not indicative of the client's condition.

5. In assessing a client with type 1 diabetes mellitus, the nurse notes that the client's respirations have changed from 16 breaths/min with a normal depth to 32 breaths/min and deep, and the client becomes lethargic. Which assessment data should the nurse obtain next?

• A. Pulse oximetry
• B. Blood glucose
• C. Arterial blood gases
• D. Serum electrolytes

Correct answer: B

Rationale: Deep, rapid respirations (Kussmaul respirations) and lethargy are signs of diabetic ketoacidosis (DKA), which occurs in uncontrolled type 1 diabetes. Checking the blood glucose is the priority to confirm hyperglycemia and guide immediate treatment. Pulse oximetry is not the priority in this situation as the issue is related to altered glucose levels, not oxygenation. Arterial blood gases and serum electrolytes may be important later in the management of DKA but are not the initial priority compared to confirming and addressing the hyperglycemia.

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