Nursing Elites

1. Following a gunshot wound to the abdomen, a young adult male had an emergency bowel resection and received multiple blood products while in the operating room. His current blood pressure is 78/52 mm Hg, he is being mechanically ventilated, and his oxygen saturation is 87%. His laboratory values include hemoglobin 7.0 g/dL, platelets 20,000/mm³, and white blood cells 1,500/mm³. Based on these assessment findings, which intervention should the nurse implement first?

• A. Transfuse packed red blood cells.
• B. Obtain blood and sputum cultures.
• C. Infuse 1000 ml of normal saline.
• D. Titrate oxygen to keep O2 saturation at 90%.

Correct answer: A

Rationale: The client is exhibiting signs of severe anemia and hypovolemic shock, indicated by low hemoglobin levels and hypotension. The first priority is to address the low hemoglobin by transfusing packed red blood cells to improve oxygen-carrying capacity and perfusion to vital organs. While obtaining blood and sputum cultures is important for identifying potential infections, infusing normal saline can help with volume expansion but does not address the primary issue of severe anemia. Titrating oxygen to maintain an oxygen saturation of 90% is crucial but should follow the administration of packed red blood cells to optimize oxygen delivery.

2. The nurse is assessing a client with chronic heart failure who is receiving furosemide (Lasix). Which assessment finding is most concerning?

• A. Heart rate of 60 beats per minute
• B. Blood pressure of 110/70 mmHg
• C. Elevated liver enzymes
• D. Elevated blood glucose level

Correct answer: C

Rationale: Elevated liver enzymes are most concerning in a client with chronic heart failure as they may indicate liver congestion or worsening heart failure, requiring immediate intervention. Elevated liver enzymes can be a sign of hepatotoxicity or liver damage, which could be a result of furosemide (Lasix) use. Monitoring liver function is crucial in patients taking furosemide due to the risk of hepatotoxicity. A heart rate of 60 beats per minute and a blood pressure of 110/70 mmHg are within normal ranges for a client with chronic heart failure. An elevated blood glucose level may be expected due to the effects of furosemide but is not as immediately concerning as elevated liver enzymes.

3. Which assessment is most important for the nurse to include in the daily plan of care for a client with a burned extremity?

• A. Distal pulse intensity
• B. Skin integrity
• C. Pain levels
• D. Range of motion

Correct answer: A

Rationale: The correct answer is A: Distal pulse intensity. Monitoring distal pulses is crucial to ensure that circulation to the extremity is not compromised. This assessment helps in detecting any signs of decreased circulation, which is vital in managing a burned extremity. While skin integrity (choice B), pain levels (choice C), and range of motion (choice D) are also important assessments, monitoring distal pulse intensity takes precedence as it directly reflects the perfusion status of the affected extremity in a burned client.

4. An elderly male client is admitted to the urology unit with acute renal failure due to a postrenal obstruction. Which question best assists the nurse in obtaining relevant historical data?

• A. Have you had any difficulty starting your urinary stream?
• B. Do you have a history of kidney stones?
• C. How much fluid do you drink daily?
• D. Have you had any previous urinary tract infections?

Correct answer: A

Rationale: The correct answer is A: 'Have you had any difficulty starting your urinary stream?' This question is the most relevant as difficulty starting urination can indicate an obstruction, which aligns with the client's current condition of postrenal obstruction causing acute renal failure. Choice B is incorrect as a history of kidney stones may not be directly related to the current obstruction. Choice C, asking about daily fluid intake, is not specific to the current issue of postrenal obstruction. Choice D inquires about previous urinary tract infections, which are not directly related to the current acute renal failure caused by postrenal obstruction.

5. A client with liver cirrhosis and severe ascites has a serum sodium level of 115 mEq/L and is receiving 3% saline IV. Which assessment finding indicates that the nurse should notify the healthcare provider?

• A. The client's serum sodium level is now 130 mEq/L
• B. The client reports a headache and has a BP of 140/90
• C. The client reports shortness of breath and has an O2 saturation of 92%
• D. The client has crackles in both lung bases and an increased respiratory rate.

Correct answer: D

Rationale: The presence of crackles in both lung bases and an increased respiratory rate indicates fluid overload, which can be exacerbated by hypertonic saline. This condition can worsen the client's respiratory status and lead to further complications. The other options do not directly relate to the fluid overload caused by the hypertonic saline. A serum sodium level of 130 mEq/L is within a normal range for treatment. A headache and a blood pressure of 140/90 are not specific indicators of worsening condition related to hypertonic saline. Shortness of breath and an O2 saturation of 92% could be related to other factors in a client with liver cirrhosis and ascites.

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