Nursing Elites

1. The nurse is caring for a client with a diagnosis of pneumonia who has been febrile for 24 hours. Which data is most important for the nurse to obtain in determining the client's fluid status?

• A. Daily intake and output
• B. Skin turgor
• C. Daily weight
• D. Vital signs every 4 hours

Correct answer: C

Rationale: Daily weight is the most important data for the nurse to obtain in determining the client's fluid status in this scenario. During febrile episodes, assessing daily weight is crucial as it can indicate fluid retention or loss. While monitoring intake and output is important for assessing fluid balance, daily weight provides a more comprehensive picture of fluid status over time. Skin turgor is more indicative of hydration status than overall fluid status, and vital signs, although essential, do not directly assess fluid status as effectively as daily weight.

2. The nurse is triaging clients from a train wreck. A client has multiple open wounds, a blood pressure of 90/56, and a pulse of 112 beats/minute. Which triage tag color should the nurse place on this client?

• A. Black
• B. Yellow
• C. Green
• D. Red

Correct answer: D

Rationale: The correct answer is D: Red. The client's vital signs indicate critical condition with a high pulse and low blood pressure, suggesting shock. A red tag is used to identify patients who require immediate attention and should be prioritized for treatment. Choice A, Black, is incorrect as it is typically used for deceased or expectant clients. Choice B, Yellow, is used for clients with non-life-threatening injuries who require medical care but can wait. Choice C, Green, is for clients with minor injuries who can wait the longest for treatment. Therefore, in this scenario, the client's condition warrants a red triage tag for immediate attention.

3. A client who has a flaccid bladder is placed on a bladder training program. Which instruction should the nurse include in this client's teaching plan?

• A. Use manual pressure to express urine
• B. Perform the Crede maneuver
• C. Apply an external urinary drainage device
• D. Take a warm sitz bath twice a day

Correct answer: B

Rationale: The correct answer is B: Perform the Crede maneuver. The Crede maneuver is a technique used to manage a flaccid bladder by applying manual pressure over the bladder area to assist in the expulsion of urine. This technique helps promote bladder emptying. Choice A is incorrect because using manual pressure to express urine is not a standardized technique and may cause harm. Choice C is incorrect as applying an external urinary drainage device does not address the need for bladder training. Choice D is unrelated to bladder training for a flaccid bladder.

4. A client who had an intraosseous (IO) cannula placed by the healthcare provider for emergent fluid resuscitation is complaining of severe pain and numbness below the IO site. The skin around the site is pale and edematous. What action should the nurse take first?

• A. Discontinue the IO infusion
• B. Administer an analgesic via the IO site
• C. Elevate the extremity with the IO site
• D. Notify the healthcare provider

Correct answer: A

Rationale: In this scenario, the client's symptoms of severe pain, numbness, pale skin, and edema below the IO site raise concerns for complications like compartment syndrome or extravasation. The priority action for the nurse is to discontinue the IO infusion to prevent further harm to the client. Administering an analgesic via the IO site or elevating the extremity with the IO site may delay addressing the potential serious complications. While notifying the healthcare provider is important, the immediate action to ensure client safety is to stop the infusion.

5. The nurse is caring for a client who is receiving morphine sulfate via a patient-controlled analgesia (PCA) pump. Which action is most important for the nurse to implement?

• A. Monitor the client's respiratory status
• B. Teach the client how to use the PCA pump
• C. Evaluate the client's pain level
• D. Assess the client's pain level

Correct answer: A

Rationale: The correct answer is to monitor the client's respiratory status. When administering opioids like morphine sulfate via a PCA pump, it is crucial to closely monitor the client's respiratory status to detect signs of respiratory depression early. This is important for ensuring the client's safety while receiving pain management. Choices B, C, and D are incorrect because while teaching the client to use the PCA pump and assessing or evaluating their pain level are essential aspects of care, monitoring respiratory status takes precedence due to the potential risks associated with opioid use.

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