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 with osteoporosis related to long-term corticosteroid therapy receives a prescription for calcium carbonate. Which client’s serum laboratory value requires intervention by the nurse?

• A. Total calcium 9 mg/dl (2.25 mmol/L SI)
• B. Creatinine 4 mg/dl (354 micromol/L SI)
• C. Phosphate 4 mg/dl (1.293 mmol/L SI)
• D. Fasting glucose 95 mg/dl (5.3 mmol/L SI)

Correct answer: B

Rationale: An elevated creatinine level indicates possible renal impairment, which requires intervention. High creatinine levels are associated with decreased kidney function, and in this case, it suggests potential renal issues due to long-term corticosteroid therapy. Monitoring renal function is crucial in clients with osteoporosis on corticosteroid therapy to prevent further complications. Total calcium levels within the normal range are suitable for a client with osteoporosis receiving calcium carbonate. Phosphate and fasting glucose levels do not directly indicate renal impairment in this scenario.

3. A young female adult wanders into the Emergency Department. She is disheveled and confused and states, 'My date must have put something in my drink. He took my car, and I think he raped me. I don't exactly remember, but I know he hurt me.' How should the nurse respond?

• A. Did you try to resist or fight back when you felt uncomfortable?
• B. He hurt you? Can you elaborate on what happened?
• C. It is okay to cry, but first, let's address your injuries and the situation.
• D. Yes, I can see. Tell me more about what you remember.

Correct answer: D

Rationale: The correct response is to encourage the patient to share more about what she remembers. This approach helps gather crucial information, supports the patient in a non-judgmental manner, and allows the nurse to provide appropriate care. Choice A has been revised to be more sensitive by asking about resistance when feeling uncomfortable rather than placing blame. Choice B has been adjusted to show empathy and request more details without questioning the patient's account. Choice C, although empathetic, does not address the immediate need to collect information and support the patient.

4. Prior to surgery, written consent must be obtained. What is the nurse’s legal responsibility with regard to obtaining written consent?

• A. Validate the client's understanding of the surgical procedure to be conducted
• B. Explain the surgical procedure to the client and ensure the client comprehends before signing the consent form
• C. Ensure the client, not a family member, signs the surgical consent form
• D. Confirm that the surgical consent form is signed and included in the client's record

Correct answer: A

Rationale: The nurse's legal responsibility in obtaining written consent is to validate the client's understanding of the surgical procedure to be conducted. This process ensures that the client has been comprehensively informed about the procedure, including its risks, benefits, and alternatives. Choice B is incorrect because it does not emphasize the validation of client understanding, which is crucial for informed consent. Choice C is incorrect as the client, not a family member, should provide consent unless specific circumstances dictate otherwise. Choice D is incorrect because although ensuring the consent form is signed and filed is important, it does not address the primary responsibility of confirming the client's comprehension and ensuring informed consent.

5. The nurse is caring for a newborn who arrives in the nursery following a precipitous birth on the way to the hospital. A drug screen of the mother reveals the presence of cocaine metabolites. The infant has a heart rate of 175 beats/minute, cries continuously, is irritable, and is hyperreactive to stimuli. Which intervention is most important for the nurse to include in this infant’s plan of care?

• A. Initiate infant sepsis protocol
• B. Implement seizure precautions
• C. Refer to protective child services
• D. Formula feed every 3 hours

Correct answer: B

Rationale: The infant's symptoms, such as a high heart rate, continuous crying, irritability, and hyperreactivity, suggest possible withdrawal effects due to maternal cocaine use. These symptoms can lead to seizures. Therefore, the priority intervention is to implement seizure precautions to ensure the infant's safety. Initiating the infant sepsis protocol is not indicated based on the symptoms presented. Referring to protective child services is important but not the immediate priority. Formula feeding every 3 hours is a routine care measure but does not address the urgent need to prevent potential seizures.

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