Nursing Elites

1. An unlicensed assistive personnel (UAP) reports to the nurse that a client with a postoperative wound infection has a temperature of 103°F (39.4°C), blood pressure of 90/70, pulse of 124 beats/minute, and respirations of 28 breaths/minute. When assessing the client, findings include mottled skin appearance and confusion. Which action should the nurse take first?

• A. Transfer the client to the ICU.
• B. Initiate an infusion of intravenous (IV) fluids.
• C. Assess the client's core temperature.
• D. Obtain a wound specimen for culture.

Correct answer: B

Rationale: Initiating an infusion of IV fluids is the priority action to stabilize blood pressure in a client with signs of sepsis. Intravenous fluids help maintain perfusion to vital organs and prevent further deterioration. Option A is not the immediate priority as stabilizing the client's condition can be initiated in the current setting. Option C, assessing the client's core temperature, is important but not the most critical action at this time. Option D, obtaining a wound specimen for culture, is important for identifying the causative organism but is not the first priority in managing a client with signs of sepsis.

2. The provider has ordered Kayexalate and sorbitol to be administered to a patient. The nurse caring for this patient would expect which serum electrolyte values prior to administration of this therapy?

• A. Sodium 125 mEq/L and potassium 2.5 mEq/L
• B. Sodium 150 mEq/L and potassium 3.6 mEq/L
• C. Sodium 135 mEq/L and potassium 6.9 mEq/L
• D. Sodium 148 mEq/L and potassium 5.5 mEq/L

Correct answer: C

Rationale: Severe hyperkalemia, with a potassium level of 6.9 mEq/L, requires aggressive treatment with Kayexalate and sorbitol to increase the body’s excretion of potassium. The normal range for serum potassium is 3.5 to 5.5 mEq/L, so patients with the other potassium levels would not be treated aggressively or would need potassium supplementation. Therefore, option C (Sodium 135 mEq/L and potassium 6.9 mEq/L) is the correct choice as it indicates severe hyperkalemia warranting the administration of Kayexalate and sorbitol. Options A, B, and D have either potassium levels within normal limits, which would not necessitate this aggressive treatment, or potassium levels that are lower than what would typically prompt the need for Kayexalate and sorbitol.

3. A client with polycystic kidney disease (PKD is being assessed by a nurse. Which assessment finding should prompt the nurse to immediately contact the healthcare provider?

• A. Flank pain
• B. Periorbital edema
• C. Bloody and cloudy urine
• D. Enlarged abdomen

Correct answer: B

Rationale: Periorbital edema would not typically be associated with polycystic kidney disease (PKD) and could indicate other underlying issues that require immediate attention. Flank pain and an enlarged abdomen are common findings in PKD due to kidney enlargement and displacement of other organs. Bloody or cloudy urine can result from cyst rupture or infection, which are expected in PKD. Therefore, periorbital edema is the most alarming finding in this scenario and warrants prompt notification of the healthcare provider.

4. A client is tested for HIV with the use of an enzyme-linked immunosorbent assay (ELISA), and the test result is positive. The nurse should tell the client that:

• A. HIV infection has been confirmed
• B. The client probably has an opportunistic infection
• C. The test will need to be confirmed with the use of a Western blot
• D. A positive test is a normal result and does not mean that the client is infected with HIV

Correct answer: C

Rationale: When an ELISA test for HIV is positive, it is essential to confirm the result with a Western blot. The Western blot is the confirmatory test for HIV. Choice A is incorrect because a positive ELISA test does not confirm HIV infection. Choice B is incorrect as it assumes a different diagnosis. Choice D is incorrect because a positive ELISA test does indicate potential HIV infection and requires confirmation.

5. A client who has just undergone a skin biopsy is listening to discharge instructions from the nurse. The nurse determines that the client has misunderstood the directions if the client indicates that as part of aftercare he plans to:

• A. Use the antibiotic ointment as prescribed
• B. Return in 7 days to have the sutures removed
• C. Apply cool compresses to the site twice a day for 20 minutes
• D. Call the physician if excessive drainage from the wound occurs

Correct answer: C

Rationale: The correct answer is C. Applying cool compresses to the site twice a day for 20 minutes is not a recommended aftercare practice for a skin biopsy. After a skin biopsy, it is important to keep the dressing dry and in place for a minimum of 8 hours. Choice A is correct as using the antibiotic ointment as prescribed is a common post-biopsy instruction to prevent infection. Choice B is also correct as returning in 7 days to have the sutures removed is part of the typical follow-up care after a skin biopsy. Choice D is correct as it is important to call the physician if excessive drainage from the wound occurs to prevent complications.

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