Nursing Elites

1. The healthcare provider is caring for a client with severe anemia. Which assessment finding requires immediate intervention?

• A. Pale skin
• B. Increased heart rate
• C. Shortness of breath
• D. Fatigue

Correct answer: C

Rationale: Shortness of breath is a critical sign in severe anemia as it indicates inadequate oxygenation, which can be life-threatening. Immediate intervention is necessary to address this condition. Pale skin (choice A) is a common finding in anemia but not as urgent as shortness of breath. Increased heart rate (choice B) is a compensatory mechanism in anemia to maintain oxygen delivery and is important but not as urgent as addressing inadequate oxygenation. Fatigue (choice D) is a common symptom in anemia but does not indicate an immediate life-threatening situation like shortness of breath does.

2. A client is receiving IV antibiotic therapy for sepsis. Which assessment finding indicates that the client's condition is improving?

• A. Urine output increases to 25 mL/hour
• B. Client reports feeling less fatigued
• C. Heart rate decreases from 120 to 110 beats per minute
• D. White blood cell count decreases from 15,000 to 9,000/mm3

Correct answer: D

Rationale: The correct answer is D. A decrease in white blood cell count indicates that the infection is responding to treatment, making this the most objective indicator of improvement in a client with sepsis. Choices A, B, and C are subjective indicators and may not always directly correlate with the resolution of the underlying infection. While an increase in urine output, a client reporting feeling less fatigued, and a decrease in heart rate are positive signs, they are not as specific or directly related to the resolution of the infection as a decrease in white blood cell count.

3. To auscultate for a carotid bruit, where should the nurse place the stethoscope?

• A. Base of the neck on the right side
• B. Above the clavicle
• C. Over the sternum
• D. Over the trachea

Correct answer: A

Rationale: To auscultate for a carotid bruit, the nurse should place the stethoscope at the base of the neck, near the carotid artery. A carotid bruit is an abnormal sound that indicates turbulent blood flow in the carotid artery, potentially due to arterial narrowing or atherosclerosis. Placing the stethoscope above the clavicle, over the sternum, or over the trachea would not provide the nurse with the optimal location to assess for carotid artery abnormalities.

4. A client with tuberculosis is prescribed rifampin. What side effect should the nurse inform the client about?

• A. Report orange-colored urine as a sign of kidney dysfunction.
• B. Expect red-orange discoloration of urine as a harmless side effect.
• C. Monitor for signs of liver toxicity.
• D. Call the healthcare provider if vision changes occur.

Correct answer: B

Rationale: The correct answer is B. Rifampin can cause red-orange discoloration of bodily fluids, including urine, saliva, and tears. This is a harmless side effect, but clients should be informed beforehand to prevent alarm. Choice A is incorrect as orange-colored urine is not a sign of kidney dysfunction related to rifampin. Choice C is incorrect because rifampin is more commonly associated with liver toxicity rather than kidney dysfunction. Choice D is incorrect as vision changes are not a typical side effect of rifampin.

5. A client with diabetes mellitus is scheduled for surgery, and their blood glucose level is 280 mg/dL. What is the nurse's priority action?

• A. Administer insulin as prescribed.
• B. Delay surgery until the blood glucose is below 180 mg/dL.
• C. Check the client’s hemoglobin A1C level.
• D. Administer IV fluids to flush excess glucose.

Correct answer: A

Rationale: The correct answer is A: Administer insulin as prescribed. In clients with diabetes, high blood glucose levels can increase the risk of infection and impair healing after surgery. Administering insulin as prescribed helps reduce blood glucose to a safer level before surgery, preventing complications. Choice B is incorrect because delaying surgery without addressing the high blood glucose level does not address the immediate issue. Choice C is incorrect as checking the client's hemoglobin A1C level is not the priority when dealing with acute high blood glucose levels before surgery. Choice D is incorrect as administering IV fluids may help with hydration but does not directly address the high blood glucose level that needs immediate attention.

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