Nursing Elites

1. Following morning care, a client with C-5 spinal cord injury who is sitting in a wheelchair becomes flushed and complains of a headache. Which intervention should the nurse implement first?

• A. Check for any kinks or obstructions in the client’s Foley tubing
• B. Assess the client’s blood pressure every 15 minutes
• C. Administer a prescribed PRN dose of hydralazine (Apresoline)
• D. Educate the client on recognizing symptoms of dysreflexia

Correct answer: B

Rationale: In a client with a C-5 spinal cord injury experiencing flushing and a headache, the priority intervention is to assess the client's blood pressure every 15 minutes. These symptoms could indicate autonomic dysreflexia, a potentially life-threatening condition. Assessing the blood pressure is crucial to identify and address this emergency situation promptly. Checking for kinks or obstructions in the Foley tubing (Choice A) is important but not the priority in this scenario. Administering hydralazine (Choice C) without knowing the blood pressure could be harmful as it may lead to a sudden drop in blood pressure. Educating the client on recognizing symptoms of dysreflexia (Choice D) is important for long-term management but is not the immediate action needed in this acute situation.

2. Following a gunshot wound, an adult client has a hemoglobin level of 4 grams/dl (40 mmol/L SI). The nurse prepares to administer a unit of blood for an emergency transfusion. The client has AB negative blood type and the blood bank sends a unit of type A Rh negative, reporting that there is not type AB negative blood currently available. Which intervention should the nurse implement?

• A. Transfuse Type A negative blood until type AB negative is available.
• B. Recheck the client’s hemoglobin, blood type, and Rh factor.
• C. Administer normal saline solution until type AB negative is available.
• D. Obtain additional consent for the administration of type A negative blood.

Correct answer: A

Rationale: In emergency situations where AB negative blood is unavailable, type A negative blood can be transfused to a patient with AB negative blood type. Type A negative blood is compatible with AB negative blood, making it a suitable option until the correct blood type becomes available. Transfusion of Type A negative blood is crucial to address the severe anemia promptly. Rechecking the client’s hemoglobin, blood type, and Rh factor (Choice B) may delay necessary treatment. Administering normal saline solution (Choice C) is not a substitute for blood transfusion in cases of severe anemia. Obtaining additional consent for the administration of type A negative blood (Choice D) is unnecessary as the situation is emergent and the blood type is compatible.

3. The healthcare provider explains through an interpreter the risks and benefits of a scheduled surgical procedure to a non-English speaking female client. The client gives verbal consent, and the healthcare provider leaves, instructing the nurse to witness the signature on the consent form. The client and interpreter then speak together in the foreign language for an additional 2 minutes until the interpreter concludes, 'She says it is OK.' What action should the nurse take next?

• A. Clarify the client’s consent through the use of gestures and simple terms
• B. Have the interpreter co-sign the consent to validate the client's understanding
• C. Ask for a full explanation from the interpreter of the witnessed discussion
• D. Have the client sign the consent form and the nurse witness the signature

Correct answer: B

Rationale: Having the interpreter co-sign the consent form is the most appropriate action in this scenario. By having the interpreter co-sign, it ensures an additional layer of verification of the client's understanding and consent, which is crucial when language barriers exist. This step adds a level of confirmation to safeguard that the client's consent is both valid and well-informed. Option A is not sufficient as gestures and simple terms may not fully clarify the client's understanding, especially for complex medical procedures. Option C is unnecessary since the interpreter has already confirmed the client's consent. Option D does not involve the interpreter in validating the client's understanding, which is essential in this situation to ensure effective communication and comprehension between the client and the healthcare team.

4. When caring for a client with Cushing syndrome, which serum laboratory value is most important for the nurse to monitor?

• A. Lactate
• B. Glucose
• C. Hemoglobin
• D. Creatinine

Correct answer: B

Rationale: When caring for a client with Cushing syndrome, monitoring glucose levels is crucial as Cushing syndrome often leads to hyperglycemia. Elevated glucose levels are a common manifestation of Cushing syndrome due to increased cortisol levels. Monitoring glucose helps in assessing and managing the client's condition effectively. Lactate levels are not typically affected by Cushing syndrome. Hemoglobin and creatinine levels are important for other conditions like anemia and kidney function, but they are not the priority in Cushing syndrome.

5. When gathering subjective data from a client, what intervention should the nurse implement first?

• A. Listen attentively
• B. Establish rapport
• C. List problems
• D. Clarify inferences

Correct answer: B

Rationale: Establishing rapport is the initial step the nurse should take when gathering subjective data from a client. Building trust and a good relationship with the client creates an environment where the client feels comfortable sharing accurate and honest information. Listening attentively is important but should come after rapport is established to enhance active listening. Listing problems and clarifying inferences are actions that occur later in the assessment process, after the nurse has established a good rapport and obtained a comprehensive understanding of the client's perspective. Therefore, option B is the correct answer.

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