Nursing Elites

1. The healthcare provider is caring for a client with a history of hypertension. Which assessment finding would be most concerning?

• A. Blood pressure of 150/90 mmHg
• B. Irregular heart rate
• C. Shortness of breath
• D. Headache

Correct answer: C

Rationale: Shortness of breath in a client with a history of hypertension is a critical assessment finding as it may indicate heart failure, pulmonary edema, or other severe complications. The development of shortness of breath suggests that the client's condition may be rapidly deteriorating and requires immediate medical attention. Elevated blood pressure (150/90 mmHg) is concerning but not as acute as the potential complications associated with shortness of breath. An irregular heart rate and headache can also be symptoms of hypertension, but in this scenario, shortness of breath poses a higher risk of severe cardiovascular or respiratory issues.

2. A client with Guillain-Barre syndrome is in a non-responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition?

• A. Comatose, breathing unlabored
• B. Glasgow Coma Scale 8, respirations regular
• C. Appears to be sleeping, vital signs stable
• D. Glasgow Coma Scale 13, no ventilator required

Correct answer: B

Rationale: The correct answer is B: 'Glasgow Coma Scale 8, respirations regular.' A Glasgow Coma Scale of 8 with regular respirations accurately describes a non-responsive state with independent breathing. Choice A is incorrect because 'comatose' implies a deep state of unconsciousness, which may not be accurate in this case. Choice C is incorrect as stating the client 'appears to be sleeping' may not accurately reflect the severity of the situation. Choice D is incorrect because a Glasgow Coma Scale of 13 would not typically correspond to a non-responsive state.

3. When providing postmortem care to a client diagnosed with Methicillin-resistant Staphylococcus aureus (MRSA) who has passed away, what type of precautions is appropriate to use?

• A. Airborne precautions
• B. Droplet precautions
• C. Contact precautions
• D. Compromised host precautions

Correct answer: C

Rationale: Contact precautions are the appropriate type to use when performing postmortem care for a client with MRSA. MRSA is primarily spread through direct contact, so using contact precautions helps prevent the transmission of the infection. Airborne precautions are not necessary for MRSA, as it is not transmitted through the air like tuberculosis or measles. Droplet precautions are used for diseases transmitted through respiratory droplets like influenza. Compromised host precautions are not a standard precaution type and are not specific to managing MRSA infection.

4. A healthcare professional is preparing to administer 0.9% sodium chloride (0.9% NaCl) 250 mL IV to infuse over 30 min. The drop factor of the manual IV tubing is 10 gtt/mL. How many gtt/min should the healthcare professional adjust the manual IV infusion to deliver? (Round the answer to the nearest whole number. Do not use a trailing zero.)

• A. 83 gtt/min
• B. 125 gtt/min
• C. 100 gtt/min
• D. 75 gtt/min

Correct answer: C

Rationale: To administer 250 mL over 30 min with a drop factor of 10 gtt/mL, the healthcare professional should adjust the IV infusion to deliver 100 gtt/min. The correct calculation is: (250 mL ÷ 30 min) x 10 gtt/mL = 100 gtt/min. This rate ensures the proper administration of the IV solution within the specified time frame. Choices A, B, and D are incorrect as they do not align with the accurate calculation based on the provided data.

5. A nurse is planning strategies to manage time effectively for client care. What should the nurse implement?

• A. Use the planning step of the nursing process to prioritize client care delivery.
• B. Delegate all tasks to assistive personnel.
• C. Focus on completing tasks in the order they are assigned.
• D. Avoid using a checklist for daily tasks.

Correct answer: A

Rationale: The correct answer is A. Using the planning step of the nursing process to prioritize client care delivery is crucial for effective time management. By prioritizing tasks based on client needs and acuity levels, the nurse can ensure that the most critical care is provided in a timely manner. Choice B is incorrect because while delegation is important, not all tasks can be delegated, and the nurse is ultimately responsible for the care provided. Choice C is incorrect as completing tasks in the order they are assigned may not align with the urgency of client needs. Choice D is incorrect as using a checklist can help the nurse stay organized and ensure that all necessary tasks are completed.

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