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. A client who had surgery yesterday is becoming increasingly anxious. The client’s respiratory rate has increased to 38 breaths/minute. The client has a nasogastric tube to low intermittent suction with 500 ml of yellow-green drainage over the last four hours. The client's arterial blood gases (ABGs) indicate a decreased CO2 and an increased serum pH. Which serum laboratory value should the nurse monitor first?

• A. Electrolytes.
• B. Creatinine.
• C. Blood urea nitrogen.
• D. Glucose.

Correct answer: A

Rationale: The correct answer is A, Electrolytes. In this scenario, the client is at risk for metabolic alkalosis due to the loss of gastric secretions through the nasogastric tube. Monitoring electrolytes is crucial to assess the levels of sodium, potassium, chloride, and bicarbonate, which are important in maintaining the acid-base balance of the body. Changes in these electrolyte levels can provide valuable information about the client's fluid status and acid-base balance. Creatinine, blood urea nitrogen, and glucose levels are important parameters to monitor in different situations but are not the priority in this case of potential metabolic alkalosis.

3. A client is receiving a secondary infusion of erythromycin 1 gram in 100 mL dextrose 5% in water (D5W) to be infused in 45 minutes. How many mL/hour should the nurse program the infusion pump?

• A. 100 mL/hour.
• B. 125 mL/hour.
• C. 133 mL/hour.
• D. 150 mL/hour.

Correct answer: C

Rationale: To infuse 100 mL in 45 minutes, the infusion rate should be set to 133 mL/hour (100 mL / 0.75 hours). This calculation is obtained by dividing the total volume to be infused by the total time for infusion (100 mL / 0.75 hours = 133 mL/hour). Therefore, choice C is the correct answer. Choices A, B, and D are incorrect because they do not accurately calculate the infusion rate required to deliver the medication within the specified time frame.

4. The nurse is caring for a child who has been diagnosed with attention deficit hyperactivity disorder (ADHD). What is the most important intervention for the nurse?

• A. Help the child enroll in a special education class.
• B. Allay any feelings of guilt the parents may have.
• C. Explain to the parents that medications are lifelong.
• D. Teach the parents how to set limits.

Correct answer: B

Rationale: The most important intervention for the nurse in caring for a child with ADHD is to allay any feelings of guilt the parents may have. Parents of children with ADHD often experience guilt or self-blame, thinking they are responsible for their child's condition. By addressing and alleviating these feelings, the nurse can support the parents in a crucial way. Choice A is not the most important intervention because enrolling the child in a special education class might be a consideration but does not address the emotional needs of the parents. Choice C is incorrect because stating that medications are lifelong may cause unnecessary distress to the parents. Choice D is also not the most important intervention as setting limits is important but not as critical as addressing parental guilt and emotions.

5. A client who experienced partial-thickness burns with over 50% body surface area (BSA) 2 weeks ago suddenly becomes restless and agitated.

• A. Increase the room temperature.
• B. Assess the oxygen saturation.
• C. Continue to monitor vital signs.
• D. Notify the rapid response team.

Correct answer: D

Rationale: In a burn patient with sudden restlessness and agitation, it is crucial to consider hypoxia or other critical conditions. As such, notifying the rapid response team is the most appropriate action to ensure prompt assessment and intervention. Increasing room temperature (Choice A) is not the priority in this scenario. While monitoring vital signs (Choice C) is important, the sudden change in behavior warrants immediate action. Assessing oxygen saturation (Choice B) is a step in the right direction, but involving the rapid response team ensures a comprehensive evaluation and timely management of the patient's condition.

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