Nursing Elites

1. The healthcare provider prescribes a sepsis protocol for a client with multi-organ failure caused by a ruptured appendix. Which intervention is most important for the nurse to include in the care plan?

• A. Ensure early ambulation
• B. Administer antibiotics as prescribed
• C. Maintain strict intake and output
• D. Monitor blood glucose levels

Correct answer: C

Rationale: In sepsis with multi-organ failure, monitoring intake and output is critical to assess renal function and fluid balance, as organ failure can cause fluid shifts and decreased kidney function. Antibiotics are essential to treat the infection, but monitoring intake and output provides real-time insight into the client's status, helping to detect early signs of worsening organ function. Early ambulation and blood glucose monitoring are important aspects of care but are not as crucial as maintaining strict intake and output in this situation.

2. What safety measure should the nurse take for a client with a seizure disorder who has an IV line?

• A. Ensure that the IV site is padded and protected.
• B. Limit the client's mobility to prevent dislodging the IV.
• C. Place the IV site on the same side as the seizure activity.
• D. Ensure the client is positioned on the opposite side of the IV line.

Correct answer: D

Rationale: The correct answer is D: Ensure the client is positioned on the opposite side of the IV line. Placing the IV line on the opposite side of any seizure activity is essential to prevent injury. It helps to ensure that the IV line is not dislodged during a seizure. Choices A, B, and C are incorrect. While padding and protecting the IV site is important, the priority is to position the client on the side opposite to the IV line to prevent dislodgement and injury during a seizure.

3. A client is receiving IV antibiotic therapy for sepsis. Which assessment finding indicates that the client's condition is improving?

• A. Urine output increases to 25 mL/hour
• B. Client reports feeling less fatigued
• C. Heart rate decreases from 120 to 110 beats per minute
• D. White blood cell count decreases from 15,000 to 9,000/mm3

Correct answer: D

Rationale: The correct answer is D. A decrease in white blood cell count indicates that the infection is responding to treatment, making this the most objective indicator of improvement in a client with sepsis. Choices A, B, and C are subjective indicators and may not always directly correlate with the resolution of the underlying infection. While an increase in urine output, a client reporting feeling less fatigued, and a decrease in heart rate are positive signs, they are not as specific or directly related to the resolution of the infection as a decrease in white blood cell count.

4. The nurse is evaluating the laboratory reports of a client with hypothyroidism. The nurse would expect which of the following laboratory values?

• A. Increased TSH
• B. Increased thyroxine (T4)
• C. Decreased TSH
• D. Decreased T3

Correct answer: A

Rationale: The correct answer is A: Increased TSH. In hypothyroidism, the thyroid gland is underactive, leading to low levels of thyroid hormones. As a compensatory mechanism, the pituitary gland releases more thyroid-stimulating hormone (TSH) to try to stimulate the thyroid gland to produce more hormones. Therefore, increased TSH levels are expected in hypothyroidism. Choice B is incorrect because in hypothyroidism, thyroxine (T4) levels are usually decreased, not increased. Choice C is incorrect as hypothyroidism is characterized by increased TSH levels, not decreased. Choice D is also incorrect because in hypothyroidism, T3 levels may be decreased, but TSH is a more sensitive indicator for diagnosis.

5. A child is admitted with bacterial meningitis. What assessment finding should the nurse monitor most closely?

• A. Monitor the client’s skin for rash and lesions.
• B. Monitor for signs of increased intracranial pressure.
• C. Monitor the client’s blood pressure closely.
• D. Monitor for changes in heart rate and rhythm.

Correct answer: B

Rationale: Correct Answer: B. Signs of increased intracranial pressure, such as changes in consciousness or pupil reactivity, are critical to monitor in children with bacterial meningitis to prevent complications. Monitoring the client’s skin for rash and lesions (Choice A) is not the priority in bacterial meningitis. While monitoring blood pressure (Choice C) is important, signs of increased intracranial pressure take precedence. Monitoring for changes in heart rate and rhythm (Choice D) is less specific to the condition and may not indicate worsening neurological status.

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