Nursing Elites

1. The nurse is obtaining a client's fingerstick glucose level. After gently milking the client's finger, the nurse observes that the distal tip of the finger appears reddened and engorged. What action should the nurse take?

• A. Collect the blood sample
• B. Assess radial pulse volume
• C. Apply pressure to the site
• D. Select another finger

Correct answer: A

Rationale: When the nurse observes that the distal tip of the client's finger is reddened and engorged after milking, it indicates adequate blood flow. At this point, the appropriate action is to collect the blood sample for glucose level testing. Assessing radial pulse volume (Choice B) is unrelated to the situation and not necessary. Applying pressure to the site (Choice C) may disrupt the blood sample collection process. Selecting another finger (Choice D) is not warranted as the engorgement indicates sufficient blood flow for sampling.

2. While walking to the mailbox, an older adult male experiences sudden chest tightness and drives himself to the emergency department. When the client gets up to the desk of the triage nurse, he says his heart is pounding out of his chest as he clutches his chest and falls to the floor. Which intervention should the nurse implement first?

• A. Prepare for cardiac defibrillation.
• B. Apply cardiac monitor leads.
• C. Obtain troponin serum levels.
• D. Palpate the client’s artery.

Correct answer: D

Rationale: Palpating the client's artery is the priority intervention in this scenario because it helps determine if there is a pulse, which is crucial information in emergency situations like this. If the client is pulseless, immediate initiation of CPR is necessary. Applying cardiac monitor leads or obtaining troponin serum levels can wait until the presence of a pulse is confirmed. Cardiac defibrillation is not indicated without first assessing the client's pulse and cardiac rhythm.

3. The nurse is caring for a client with a suspected stroke. Which assessment finding is most indicative of a stroke?

• A. Chest pain
• B. Sudden confusion and difficulty speaking
• C. Gradual onset of weakness in the legs
• D. Nausea and vomiting

Correct answer: B

Rationale: The correct answer is B: Sudden confusion and difficulty speaking. These are classic signs of a stroke, indicating a neurological deficit that requires urgent medical attention. Choices A, C, and D are less indicative of a stroke. Chest pain is more commonly associated with cardiac issues, gradual onset of weakness in the legs could be related to other conditions like peripheral neuropathy, and nausea/vomiting may suggest gastrointestinal problems rather than a stroke.

4. A client with ulcerative colitis is experiencing frequent diarrhea. What is the priority nursing diagnosis?

• A. Risk for impaired skin integrity
• B. Fluid volume deficit
• C. Imbalanced nutrition: less than body requirements
• D. Activity intolerance

Correct answer: B

Rationale: The correct answer is B: Fluid volume deficit. In a client with ulcerative colitis experiencing frequent diarrhea, the priority nursing diagnosis is addressing the potential fluid volume deficit due to significant fluid loss. Maintaining adequate hydration is crucial to prevent complications associated with dehydration. While choices A, C, and D can also be concerns for a client with ulcerative colitis, addressing fluid volume deficit takes precedence as it directly impacts the client's physiological stability and can lead to serious complications if not managed promptly.

5. Which laboratory results should the nurse anticipate to be abnormal in a child with hemophilia?

• A. Prothrombin time
• B. Bleeding time
• C. Platelet count
• D. Partial thromboplastin time

Correct answer: D

Rationale: In a child with hemophilia, the nurse should anticipate an abnormality in the partial thromboplastin time (PTT) due to the deficiency in clotting factors. Prothrombin time, bleeding time, and platelet count are typically normal in hemophilia. Prothrombin time measures the extrinsic pathway of coagulation and is not affected in hemophilia. Bleeding time assesses platelet function, which is normal in hemophilia as the issue lies with clotting proteins, not platelets. Platelet count is also expected to be normal unless there is another underlying condition affecting platelet production or function.

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