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. A client is being treated for minor injuries following an automobile accident in which the only other passenger was killed. The client asks the nurse, 'Is my friend who was in the car with me ok?' What response is best for the nurse to provide?

• A. I am sorry, but your friend was killed in the accident.
• B. Right now you need to concentrate on getting well.
• C. Was the passenger in the car your friend?
• D. I think your friend is going to be all right.

Correct answer: A

Rationale: The correct answer is A: 'I am sorry, but your friend was killed in the accident.' In this situation, honesty and compassion are essential. The nurse should provide the client with truthful information, acknowledging the client's need to know the reality of the situation. Choice B is dismissive and does not address the client's inquiry directly. Choice C is a deflecting question and does not offer the direct information the client is seeking. Choice D provides false reassurance, which is not appropriate in this circumstance where the reality needs to be communicated.

3. Following an open reduction and internal fixation of a compound fracture of the leg, a male client complains of “a tingly sensation” in his left foot. The nurse determines the client’s left pedal pulses are diminished. Based on these findings, what is the client’s greatest risk?

• A. Reduce pulmonary ventilation and oxygenation related to fat embolism.
• B. Neurovascular and circulation compromise related to compartment syndrome.
• C. Wound infection and delayed healing due to fractured bone protrusion.
• D. Venous stasis and thrombophlebitis related to postoperative immobility.

Correct answer: B

Rationale: The correct answer is B. Compartment syndrome is a serious condition that can occur following trauma or surgery, leading to compromised neurovascular status in the affected limb. Symptoms include pain, paresthesia (tingling sensation), and diminished pulses. If left untreated, compartment syndrome can result in tissue damage and potential loss of limb function. Options A, C, and D are incorrect because they do not directly address the neurovascular compromise associated with compartment syndrome.

4. When assessing a client several hours after surgery, the nurse observes that the client grimaces and guards the incision while moving in bed. The client is diaphoretic, has a radial pulse rate of 110 beats/min, and a respiratory rate of 35 breaths/min. What assessment should the nurse perform first?

• A. Apical heart rate
• B. IV site and fluids
• C. Pain scale
• D. Temperature

Correct answer: C

Rationale: The client’s grimacing and guarding suggest pain; assessing the pain scale is crucial for addressing the discomfort. Pain management is a priority to ensure the client's well-being and comfort. Checking the apical heart rate, IV site and fluids, or temperature can be important but addressing the client's pain takes precedence in this scenario. The elevated pulse rate and respiratory rate could be indicative of pain, making the pain scale assessment essential to guide appropriate interventions.

5. A client is admitted with severe dehydration. What is the most important assessment finding for the nurse to monitor?

• A. Changes in mental status
• B. Urine output and color
• C. Blood pressure and heart rate
• D. Skin turgor

Correct answer: A

Rationale: Changes in mental status are crucial to monitor in a client with severe dehydration. Altered mental status, such as confusion or lethargy, can indicate severe dehydration and potential complications like electrolyte imbalances affecting the brain. Monitoring urine output and color (choice B) is essential but may not provide immediate signs of severe dehydration. While monitoring blood pressure and heart rate (choice C) is important, changes in mental status take precedence as they can indicate more critical conditions. Skin turgor (choice D) is a valuable assessment for dehydration, but changes in mental status take priority due to their direct correlation with severe dehydration.

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