Nursing Elites

1. The nurse is planning to assess a client's oxygen saturation to determine if additional oxygen is needed via nasal cannula. The client has bilateral below-the-knee amputations and weak, thread pedal pulses. What action should the nurse take?

• A. Document that an accurate oxygen saturation reading cannot be obtained
• B. Elevate the client's hands for five minutes prior to obtaining a reading from the finger
• C. Increase the oxygen based on the client's breathing patterns and lung sounds
• D. Place the oximeter clip on the earlobe to obtain the oxygen saturation reading

Correct answer: D

Rationale: Placing the oximeter clip on the earlobe is appropriate for clients with poor peripheral circulation, such as those with weak and thread pedal pulses due to bilateral below-the-knee amputations. This placement can provide a more accurate reading of oxygen saturation in such clients. Choice A is incorrect because alternative methods, such as earlobe placement, can be used to obtain accurate readings. Choice B is unnecessary and not related to obtaining an accurate oxygen saturation reading. Choice C is incorrect because increasing oxygen without assessing the oxygen saturation level first can be detrimental and is not based on evidence-based practice.

2. After a motor vehicle collision, a client is admitted to the medical unit with acute adrenal insufficiency (Addisonian crisis). Which prescription should the nurse implement?

• A. Determine serum glucose levels
• B. Withhold potassium additives to IV fluids
• C. Give IV corticosteroid replacement
• D. Prepare to initiate IV vasopressors

Correct answer: C

Rationale: In a client with acute adrenal insufficiency (Addisonian crisis) following a motor vehicle collision, the priority intervention is to administer IV corticosteroid replacement. This is crucial to manage the crisis by replacing the deficient cortisol. Determining serum glucose levels (Choice A) may be important but is not the immediate priority in this situation. Withholding potassium additives to IV fluids (Choice B) is not indicated and may exacerbate electrolyte imbalances. Initiating IV vasopressors (Choice D) is not the primary treatment for acute adrenal insufficiency and should be reserved for managing hypotension that is unresponsive to corticosteroid therapy.

3. Which laboratory finding should the nurse expect to see in a child with acute rheumatic fever?

• A. Thrombocytopenia
• B. Polycythemia
• C. Decreased ESR
• D. Positive ASO titer

Correct answer: D

Rationale: The correct answer is D: Positive ASO titer. A positive ASO titer indicates recent streptococcal infection, which is associated with acute rheumatic fever. Thrombocytopenia (choice A) is not a typical laboratory finding in acute rheumatic fever. Polycythemia (choice B) refers to an increased red blood cell count, which is not typically seen in acute rheumatic fever. Decreased ESR (choice C) is not a common laboratory finding in acute rheumatic fever; in fact, ESR is often elevated in inflammatory conditions like rheumatic fever.

4. A client is admitted to the hospital with a serum sodium level of 128 mEq/L, distended neck veins, and lung crackles. What intervention should the nurse implement?

• A. Increase the intake of salty foods
• B. Administer NaCl supplements
• C. Restrict oral fluid intake
• D. Hold the client's loop diuretic

Correct answer: C

Rationale: In the scenario described, the client presents with signs of fluid overload and hyponatremia. Restricting oral fluid intake is the appropriate intervention to manage fluid overload and correct hyponatremia. Increasing the intake of salty foods (Choice A) and administering NaCl supplements (Choice B) would exacerbate the sodium imbalance. Holding the client's loop diuretic (Choice D) is not directly related to addressing the fluid overload and hyponatremia.

5. The nurse is teaching a male adolescent recently diagnosed with type 1 diabetes mellitus (DM) about self-injecting insulin. Which approach is best for the nurse to use to evaluate the effectiveness of the teaching?

• A. Observe him demonstrating the self-injection technique to another diabetic adolescent.
• B. Ask the adolescent to describe his comfort level with injecting himself with insulin.
• C. Review his glycosylated hemoglobin level 3 months after the teaching session.
• D. Have the adolescent list the steps for safe insulin administration.

Correct answer: C

Rationale: Reviewing the glycosylated hemoglobin level after a few months is the best approach to evaluate the effectiveness of teaching self-injection. This measurement provides an objective indicator of the adolescent's glucose control over time, reflecting the impact of insulin self-administration education. Choices A, B, and D do not directly assess the long-term impact of the teaching on the adolescent's diabetes management.

Similar Questions