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. A 17-year-old adolescent is brought to the emergency department by both parents because the adolescent has been coughing and running a fever with flu-like symptoms for the past 24 hours. Which intervention should the nurse implement first?

• A. Obtain a chest X-ray per protocol.
• B. Place a mask on the client’s face.
• C. Assess the client’s temperature.
• D. Determine the client’s blood pressure

Correct answer: B

Rationale: The correct intervention for the nurse to implement first is to place a mask on the client's face. This is crucial to prevent the potential spread of infectious agents to others in the emergency department, considering the presenting symptoms of coughing and fever. Placing a mask helps in containing respiratory secretions and reducing the risk of airborne transmission. Assessing the client’s temperature or blood pressure can be done after ensuring infection control measures. Obtaining a chest X-ray would be a secondary intervention once immediate infection control is addressed.

4. A client with multiple sclerosis is receiving baclofen 15 mg PO three times daily. The drug is available in 10 mg tablets. How many tablets should the nurse administer in a 24-hour period? (Enter a numeric value only. If rounding is required, round to the nearest tenth)

• A. 4.5
• B.
• C.
• D.

Correct answer: A

Rationale: To calculate the total dose of baclofen needed in a 24-hour period, multiply 15 mg by 3 doses, which equals 45 mg. Since the tablets are available in 10 mg strength, divide the total dose needed (45 mg) by the strength of each tablet (10 mg), which equals 4.5 tablets. Rounding off to the nearest tenth, the nurse should administer 4.5 tablets of 10 mg baclofen per day. Therefore, choice A is correct. Choices B, C, and D are irrelevant as they are not provided.

5. When preparing the client for a thoracentesis, which action is essential for the nurse to take?

• A. Encourage the client to cough during the procedure
• B. Ask the client to void prior to the procedure
• C. Have the client lie in the prone position
• D. Determine if chest x-rays have been completed

Correct answer: B

Rationale: The essential action for the nurse to take when preparing a client for a thoracentesis is to ask the client to void prior to the procedure. This step is crucial as it helps prevent discomfort and reduces the risk of accidental injury. Encouraging the client to cough during the procedure (Choice A) is inappropriate as it can affect the accuracy of the thoracentesis. Having the client lie in the prone position (Choice C) is incorrect; the procedure is typically performed with the client sitting upright or slightly leaning forward. While determining if chest x-rays have been completed (Choice D) is important, ensuring the client has emptied their bladder is more critical for their comfort and safety during the procedure.

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