Nursing Elites

1. The client is undergoing progressive ambulation on the third day after a myocardial infarction. Which clinical manifestation would indicate that the client should not be advanced to the next level?

• A. Facial flushing
• B. A complaint of chest heaviness
• C. Heart rate increase of 10 beats/min
• D. Systolic blood pressure increase of 10 mm Hg

Correct answer: B

Rationale: The correct answer is a complaint of chest heaviness. Onset of chest pain indicates myocardial ischemia, which can be life-threatening. Chest pain in a client post-myocardial infarction should be promptly evaluated, and the activity level should not be advanced. Choices A, C, and D are not the best options because facial flushing, a heart rate increase of 10 beats/min, and a systolic blood pressure increase of 10 mm Hg are not typical indicators of myocardial ischemia or necessarily contraindications for advancing activity levels in this context.

2. When a client informs the nurse that he is experiencing hypoglycemia, the nurse provides immediate intervention by providing:

• A. one commercially prepared glucose tablet
• B. two hard candies
• C. 4-6 ounces of fruit juice
• D. 2-3 teaspoons of honey

Correct answer: D

Rationale: The correct immediate intervention for hypoglycemia is to provide 10-15 grams of fast-acting simple carbohydrates orally if the client is conscious and able to swallow. This can be achieved by giving 2-3 teaspoons of honey. Honey is a quick source of simple sugars that can rapidly raise blood glucose levels. Commercially prepared glucose tablets or 4-6 ounces of fruit juice are also appropriate options. However, adding sugar to fruit juice is unnecessary as the natural fruit sugar in juice already provides enough simple carbohydrates to raise blood glucose levels. Hard candies are not the best choice for immediate intervention in hypoglycemia as they may not provide a sufficient amount of fast-acting carbohydrates needed to raise blood sugar levels quickly.

3. The client is admitted to the hospital following a motor vehicle accident and has sustained a closed chest wound. Which assessment finding is consistent with a flail chest?

• A. Biot's respirations
• B. Sucking sounds during respirations
• C. Paradoxical chest wall movement
• D. Hypotension and bradycardia

Correct answer: C

Rationale: The correct assessment finding consistent with a flail chest is paradoxical chest wall movement. This occurs when a segment of the chest wall moves in the opposite direction to the rest of the chest during respiration. Biot's respirations (Choice A) are a pattern of breathing characterized by groups of quick, shallow inspirations followed by regular or irregular periods of apnea. Sucking sounds during respirations (Choice B) may indicate air entering or leaving the chest cavity through a wound. Hypotension and bradycardia (Choice D) may be present due to other factors such as shock, but they are not specific to a flail chest.

4. A client is admitted to the floor with vomiting and diarrhea for three days. She is receiving IV fluids at 200cc/hr via pump. A priority action for the nurse would be:

• A. Obtaining Intake and Output.
• B. Frequent lung assessments.
• C. Vital signs every shift.
• D. Monitoring the IV site for infiltration.

Correct answer: D

Rationale: In this scenario, the correct priority action for the nurse would be monitoring the IV site for infiltration. The client is receiving IV fluids at a rapid rate, making it crucial to ensure that the IV site is intact and not causing any complications like infiltration, which can lead to tissue damage. While frequent lung assessments are important for detecting signs of fluid overload, in this case, ensuring the IV site's integrity takes precedence. Obtaining Intake and Output is relevant but not the priority over monitoring the IV site. Vital signs are essential, but given the situation, the immediate concern is the IV site's condition to prevent complications.

5. A 22-year-old patient in a mental health lock-down unit under suicide watch appears happy about being discharged. Which of the following is probably happening?

• A. The patient is excited about being around family again.
• B. The patient's suicide plan has probably progressed.
• C. The patient's plans for the future have been clarified.
• D. The patient's mood is improving.

Correct answer: B

Rationale: In this scenario, it is concerning that a patient under suicide watch is happy about being discharged as it may indicate that the patient's suicide plan has advanced. This change in behavior should be taken seriously as it can signal an increased risk of self-harm. Choices A, C, and D are less likely as the patient's happiness about discharge in this context is more indicative of a worsening situation rather than positive outcomes like being around family, clarifying future plans, or improving mood.

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