Nursing Elites

1. Following an open reduction of the tibia, the nurse notes bleeding on the client's cast. Which action should the nurse implement?

• A. Outline the area with ink and check it every 15 minutes to see if the area has increased
• B. Notify the healthcare provider immediately
• C. Apply a new cast to stop the bleeding
• D. Elevate the limb to reduce blood flow

Correct answer: A

Rationale: After an open reduction of the tibia, bleeding on the cast can be a concern. Outlining the area with ink and monitoring it every 15 minutes is the appropriate action to assess if the bleeding is worsening, indicating the need for further intervention. This action allows for close observation without disturbing the cast. Choice B is incorrect because while notifying the healthcare provider is important, immediate action is not always necessary if the bleeding is not severe. Choice C is incorrect because applying a new cast is not the standard intervention for bleeding on a cast. Choice D is incorrect because elevating the limb may not address the underlying cause of bleeding and may not be the most appropriate action at this time.

2. A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. Which assessment finding is most concerning to the nurse?

• A. Oxygen saturation of 90%
• B. Respiratory rate of 24 breaths per minute
• C. Use of accessory muscles
• D. Inspiratory crackles

Correct answer: C

Rationale: The correct answer is C: 'Use of accessory muscles.' In a client with a history of COPD, the use of accessory muscles indicates increased work of breathing and may signal respiratory failure, necessitating immediate intervention. This finding is concerning as it suggests the client is struggling to breathe adequately. Oxygen saturation of 90% (choice A) is low but may be expected in COPD patients; it requires monitoring and intervention but is not as immediately concerning as the use of accessory muscles. A respiratory rate of 24 breaths per minute (choice B) is within a normal range and, although slightly elevated, may be a typical response to pneumonia. Inspiratory crackles (choice D) can be a common finding in pneumonia and are not as indicative of impending respiratory failure as the use of accessory muscles.

3. A client with a history of chronic heart failure is admitted with shortness of breath. Which laboratory value should be closely monitored?

• A. Serum sodium level
• B. Serum potassium level
• C. Serum creatinine level
• D. Hemoglobin level

Correct answer: B

Rationale: Corrected Rationale: In a client with chronic heart failure, serum potassium levels should be closely monitored to assess for hyperkalemia, which can worsen heart failure. Monitoring serum sodium levels is not the priority in this case. Serum creatinine level monitoring is more related to kidney function than heart failure. Hemoglobin levels are important but not the primary concern when assessing heart failure exacerbation.

4. While taking vital signs, a critically ill male client grabs the nurse's hand and asks the nurse not to leave. What action is best for the nurse to take?

• A. Pull up a chair and sit beside the client's bed.
• B. Reassure the client that you will return shortly.
• C. Ask another nurse to stay with the client.
• D. Continue taking vital signs and then leave the room.

Correct answer: A

Rationale: The best action for the nurse to take in this situation is to pull up a chair and sit beside the client's bed. By doing so, the nurse can provide emotional support and comfort to the critically ill patient who is feeling vulnerable. Sitting with the client also shows empathy and a willingness to listen to the client's needs. Reassuring the client that the nurse will return shortly (Choice B) may not address the immediate need for emotional support. Asking another nurse to stay with the client (Choice C) may not establish the same level of connection and comfort as sitting with the client personally. Continuing to take vital signs and then leaving the room (Choice D) disregards the client's emotional needs in that moment.

5. A 46-year-old male client who had a myocardial infarction 24 hours ago comes to the nurse's station fully dressed and wanting to go home. He tells the nurse that he is feeling much better at this time. Based on this behavior, which nursing problem should the nurse formulate?

• A. Ineffective coping related to denial.
• B. Risk for impaired cardiac function.
• C. Noncompliance related to lack of knowledge.
• D. Anxiety related to hospitalization.

Correct answer: A

Rationale: The correct answer is A: Ineffective coping related to denial. The client's desire to leave the hospital shortly after a myocardial infarction despite the severity of the condition indicates denial and ineffective coping. This behavior could lead to complications as the client may not adequately address his health needs. Choice B, Risk for impaired cardiac function, is not the most appropriate nursing problem in this scenario as the client's behavior is more indicative of psychological coping issues rather than a direct physiological risk at this moment. Choice C, Noncompliance related to lack of knowledge, does not align with the client's behavior of wanting to leave the hospital. Choice D, Anxiety related to hospitalization, may not be the best option as the client's behavior is more suggestive of denial rather than anxiety about being hospitalized.

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