Nursing Elites

1. The home health nurse visits a male client to provide wound care and finds the client lethargic and confused. His wife states he fell down the stairs two (2) hours ago. The nurse should

• A. Place a call to the client's healthcare provider for instructions
• B. Send him to the emergency room for evaluation
• C. Reassure the client's wife that the symptoms are transient
• D. Instruct the client's wife to call the doctor if his symptoms become worse

Correct answer: B

Rationale: In this scenario, the client is presenting with concerning symptoms of lethargy and confusion after a fall. These symptoms could indicate a serious underlying issue, such as a head injury or internal bleeding. The nurse's priority is to ensure the client receives immediate evaluation and treatment to prevent any further harm. Option B is the correct choice as it emphasizes the urgency of the situation. Choices A, C, and D are incorrect because they do not address the critical nature of the client's condition. Contacting the healthcare provider, reassuring the wife, or waiting for symptoms to worsen could delay necessary medical intervention.

2. The patient with idiopathic pulmonary arterial hypertension (IPAH) is receiving epoprostenol (Flolan). Which assessment information requires the most immediate action by the nurse?

• A. The oxygen saturation is 94%.
• B. The blood pressure is 98/56 mm Hg.
• C. The patient's central IV line is disconnected.
• D. The international normalized ratio (INR) is prolonged.

Correct answer: C

Rationale: The most immediate action required by the nurse is to address the disconnected central IV line delivering epoprostenol (Flolan). Epoprostenol has a short half-life of 6 minutes, necessitating immediate reconnection to prevent rapid clinical deterioration. While oxygen saturation, blood pressure, and INR are important parameters requiring monitoring and intervention, the priority lies in ensuring the continuous delivery of the critical medication to stabilize the patient's condition.

3. What would be the most appropriate follow-up by the home care nurse for a 57-year-old male client with a hemoglobin of 10 g/dl and a hematocrit of 32%?

• A. Ask the client if he has noticed any bleeding or dark stools
• B. Tell the client to call 911 and go to the emergency department immediately
• C. Schedule a repeat Hemoglobin and Hematocrit in 1 month
• D. Tell the client to schedule an appointment with a hematologist

Correct answer: A

Rationale: The correct answer is to ask the client if he has noticed any bleeding or dark stools. Normal hemoglobin for males is 13.0 - 18 g/dl, and normal hematocrit for males is 42 - 52%. The values of hemoglobin and hematocrit provided for the client are below normal, indicating mild anemia. The first step for the nurse is to inquire about any signs of bleeding or changes in stools that could suggest bleeding from the gastrointestinal tract. This helps in assessing the possible cause of the low hemoglobin and hematocrit levels. The other options are not appropriate as calling 911 and going to the emergency department immediately is not warranted for mild anemia, scheduling a repeat test in 1 month delays addressing the current concern, and referring the client to a hematologist may be premature without investigating the cause of the low levels first.

4. A healthcare professional is putting together a presentation on meningitis. Which of the following microorganisms has not been linked to meningitis in humans?

• A. S. pneumoniae
• B. H. influenzae
• C. N. meningitidis
• D. Cl. difficile

Correct answer: D

Rationale: The correct answer is Cl. difficile. Clostridium difficile (C. diff) is not typically associated with meningitis in humans. This bacterium is known to cause severe diarrhea, usually as a result of antibiotic treatment. S. pneumoniae, H. influenzae, and N. meningitidis are all known to be causative agents of meningitis in humans. S. pneumoniae is a common cause of bacterial meningitis, especially in adults. H. influenzae, particularly type b (Hib), used to be a leading cause of meningitis in children before the introduction of the Hib vaccine. N. meningitidis is another significant pathogen responsible for causing meningitis, especially in young adults and adolescents.

5. Which of the following can cause coup-contrecoup injuries?

• A. Rotational forces
• B. Deformation forces
• C. Deceleration forces
• D. Acceleration forces

Correct answer: C

Rationale: Deceleration forces occur when the head is moving and abruptly comes to a stop, such as in a car crash. This sudden deceleration can cause the brain to hit against the skull, resulting in coup-contrecoup injuries. In a coup-contrecoup injury, the brain is damaged on opposite sides due to the initial impact and the rebound effect inside the skull. Rotational forces usually result in diffuse axonal injuries rather than coup-contrecoup injuries. Deformation forces can cause focal brain injuries but not coup-contrecoup injuries. Acceleration forces typically lead to diffuse brain injuries, not coup-contrecoup injuries. Therefore, the correct answer is deceleration forces.

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