Nursing Elites

1. The healthcare provider is completing a head-to-toe assessment for a client admitted for observation after falling out of a tree. Which finding warrants immediate intervention by the healthcare provider?

• A. Sluggish pupillary response to light
• B. Clear fluid leaking from the nose
• C. Complaint of severe headache
• D. Periorbital ecchymosis of the right eye

Correct answer: B

Rationale: Clear fluid leaking from the nose is concerning for cerebrospinal fluid leakage, which is a medical emergency requiring immediate intervention. Sluggish pupillary response to light may indicate neurological issues but is not as urgent as CSF leakage. Complaint of severe headache is important but not as critical as the possibility of CSF leakage. Periorbital ecchymosis of the right eye could be indicative of trauma but does not pose an immediate threat to the patient's life.

2. A client admitted to the intensive care unit with syndrome of inappropriate antidiuretic hormone (SIADH) has developed osmotic demyelination. Which intervention should the nurse implement first?

• A. Patch one eye.
• B. Reorient often.
• C. Range of motion.
• D. Evaluate swallow

Correct answer: B

Rationale: Frequent reorientation is crucial for clients with neurological impairments from osmotic demyelination to prevent confusion and assist with orientation. It helps maintain a proper sense of time, place, and person, reducing disorientation. Patching one eye (Choice A) is not a priority intervention for osmotic demyelination and does not address the immediate need for reorientation. Range of motion exercises (Choice C) may be important for overall care, but reorientation takes precedence due to its impact on neurological functioning. Evaluating swallow (Choice D) is not the primary intervention needed for osmotic demyelination; it is essential but not the first priority.

3. After completion of mandatory counseling, the impaired nurse has asked nursing administration to allow return to work. When the nurse administrator approaches the charge nurse with the impaired nurse’s request, what action is best for the charge nurse to take?

• A. Ask to meet with the impaired nurse’s therapist before allowing the nurse back on the unit
• B. Meet with staff to assess their feelings about the impaired nurse’s return to the unit
• C. Since treatment is completed, assign the nurse to routine RN responsibilities
• D. Allow the impaired nurse to return to work and monitor medication administration

Correct answer: D

Rationale: Allowing the impaired nurse to return to work with monitoring is the best course of action in this scenario. By monitoring the impaired nurse's medication administration, the charge nurse can ensure safe practice while supporting the nurse's reintegration into the work environment. Meeting with the therapist (Choice A) is not within the charge nurse's scope of responsibility and may violate the impaired nurse's privacy. Assessing staff feelings (Choice B) is important but should be done by leadership, not the charge nurse. Simply assigning routine duties (Choice C) may not address the need for monitoring and support required in this situation.

4. The nurse is caring for a client who is receiving continuous ambulatory peritoneal dialysis (CAPD) and notes that the output flow is 100ml less than the input flow. Which actions should the nurse implement first?

• A. Continue to monitor intake and output with the next exchange
• B. Check the client's blood pressure and serum bicarbonate levels
• C. Irrigate the dialysis catheter
• D. Change the client's position

Correct answer: D

Rationale: In this situation, the priority action for the nurse is to change the client's position. Altering the client's position can help facilitate better fluid drainage in peritoneal dialysis, potentially resolving the issue without the need for more invasive interventions. Continuing to monitor intake and output (Choice A) is important but addressing the immediate drainage issue takes precedence. Checking blood pressure and serum bicarbonate levels (Choice B) is not directly related to the observed output flow discrepancy. Irrigating the dialysis catheter (Choice C) should not be the initial action as it is more invasive and should be considered only if repositioning does not resolve the issue.

5. Four clients arrive on the labor and delivery unit at the same time. Which client should the nurse assess first?

• A. A 38-week primigravida who reports contractions occurring every 10 minutes
• B. A 39-week primigravida with a biophysical profile score of 5 out of 8
• C. A 41-week multigravida who is scheduled for induction of labor today
• D. A 36-week multigravida with a prescription for serial blood pressure

Correct answer: B

Rationale: The correct answer is B. A biophysical profile score of 5 out of 8 indicates potential fetal distress, necessitating immediate assessment to ensure the well-being of the fetus. The other options, while important, do not suggest an immediate threat to the fetus' health. The 38-week primigravida with contractions every 10 minutes may be in early labor, the 41-week multigravida scheduled for induction can be assessed after addressing the immediate concern, and the 36-week multigravida with serial blood pressure can be assessed after ensuring the client with potential fetal distress is stabilized.

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