Nursing Elites

1. The nurse caring for a hospitalized older client with a left hip fracture as a result of a fall at home notices different assessment findings. Which assessment finding warrants immediate intervention by the nurse?

• A. Pain rated 7/10 on the pain scale.
• B. Mild swelling at the fracture site.
• C. Small amount of bleeding from the surgical site.
• D. Left extremity capillary refill greater than 5 seconds.

Correct answer: D

Rationale: The correct answer is D. A left extremity capillary refill greater than 5 seconds indicates poor blood flow to the extremity, which is a sign of compromised circulation. This finding requires immediate intervention by the nurse to prevent complications such as tissue damage or necrosis. Choices A, B, and C are important assessments but do not indicate an immediate need for intervention like the delayed capillary refill in choice D.

2. The nurse assesses an adult male client 24 hours following abdominal surgery and finds that his blood pressure is 98/40 mm Hg, he is tachycardic, restless, and irritable. Which action should the nurse take first?

• A. Notify the healthcare provider of the findings.
• B. Ensure that the IV is infusing at the prescribed rate.
• C. Listen to lung sounds.
• D. Check under his back for evidence of bleeding.

Correct answer: D

Rationale: In this scenario, the nurse should first check under the client for evidence of bleeding. A blood pressure of 98/40 mm Hg, along with tachycardia, restlessness, and irritability, could indicate internal hemorrhage following abdominal surgery. Checking for bleeding under the back is crucial to rule out this life-threatening complication. Notifying the healthcare provider, ensuring IV infusion, or listening to lung sounds can be important but are secondary to ruling out immediate life-threatening conditions like internal bleeding.

3. What are early signs of varicella disease?

• A. High fever over 101°F (38.3°C)
• B. General malaise
• C. Increased appetite
• D. Crusty sores

Correct answer: B

Rationale: The correct early sign of varicella disease is general malaise. During the prodromal period, patients may experience low-grade fever, malaise, and anorexia. Increased appetite and crusty sores are not typically early signs of varicella. The appearance of lesions occurs later in the course of the disease.

4. An overweight, young adult male who was recently diagnosed with type 2 diabetes mellitus is admitted for a hernia repair. He tells the nurse that he is feeling very weak and jittery. Which actions should the nurse implement? (Select all that apply)

• A. Check his fingerstick glucose
• B. Assess his skin temperature and moisture
• C. Measure his pulse and BP
• D. All of the Above

Correct answer: D

Rationale: In this scenario, the patient is a young adult male with type 2 diabetes mellitus admitted for a hernia repair who is experiencing weakness and jitteriness. Checking his fingerstick glucose is crucial to assess his blood sugar levels, which can directly impact his symptoms. Assessing his skin temperature and moisture is important to evaluate his peripheral circulation and hydration status. Measuring his pulse and blood pressure helps in gauging his cardiovascular status. Therefore, all the actions mentioned in choices A, B, and C are appropriate for the nurse to implement in this situation to identify the underlying cause of the patient's symptoms. Choice D, 'All of the Above,' is the correct answer because all these actions are necessary for a comprehensive assessment of the patient's condition. Choices A, B, and C are incorrect individually as they each address different aspects of the patient's condition, and a holistic approach is needed to provide optimal care in this situation.

5. The nurse uses a diagram to show that the tetralogy of Fallot involves a combination of four congenital defects. What are the defects?

• A. Aortic stenosis, atrial septal defect, overriding aorta, left ventricular hypertrophy
• B. Pulmonary stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy
• C. Aortic stenosis, atrial septal defect, overriding aorta, right ventricular hypertrophy
• D. Pulmonary stenosis, ventricular septal defect, aortic hypertrophy, left ventricular hypertrophy

Correct answer: B

Rationale: The correct answer is B: Pulmonary stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy. Tetralogy of Fallot involves these four congenital defects. Choice A is incorrect because it includes aortic stenosis instead of pulmonary stenosis, atrial septal defect instead of ventricular septal defect, and left ventricular hypertrophy instead of right ventricular hypertrophy. Choice C is incorrect as it includes aortic stenosis and atrial septal defect instead of pulmonary stenosis and ventricular septal defect. Choice D is incorrect because it includes aortic hypertrophy instead of overriding aorta.

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