Nursing Elites

1. The nurse is triaging several children as they present to the emergency room after an accident. Which child requires the most immediate intervention by the nurse?

• A. An 11-year-old with a headache, nausea, and projectile vomiting
• B. A 5-year-old with a broken arm
• C. A 7-year-old with minor abrasions
• D. A 9-year-old with a twisted ankle

Correct answer: A

Rationale: The correct answer is A. Projectile vomiting in a child with a headache could indicate increased intracranial pressure, requiring immediate attention. Choices B, C, and D do not present with symptoms indicating potentially life-threatening conditions that require urgent intervention.

2. The nurse is planning care for a client admitted with a diagnosis of pheochromocytoma. Which intervention has the highest priority for inclusion in this client's plan of care?

• A. Record urine output every hour
• B. Monitor blood pressure frequently
• C. Evaluate neurological status
• D. Maintain seizure precautions

Correct answer: B

Rationale: Monitoring blood pressure frequently is the highest priority intervention for a client diagnosed with pheochromocytoma. This rare tumor can lead to life-threatening hypertension due to catecholamine secretion. Evaluating neurological status and maintaining seizure precautions are important but are not the highest priority in this case. Recording urine output, though essential for overall assessment, is not the priority compared to monitoring blood pressure in a client with pheochromocytoma.

3. A client with a tracheostomy has thick, tenacious secretions. Which intervention should the nurse include in the plan of care?

• A. Encourage the client to drink plenty of fluids.
• B. Perform deep suctioning every 2 to 4 hours.
• C. Increase humidity in the client's room.
• D. Administer a mucolytic agent.

Correct answer: C

Rationale: Increasing humidity in the client's room can help liquefy thick secretions and facilitate easier airway clearance in a client with a tracheostomy. Encouraging the client to drink plenty of fluids can be beneficial for overall hydration but may not directly address thick secretions. Deep suctioning every 2 to 4 hours can be harmful and cause trauma to the airway lining. Administering a mucolytic agent should be done under the healthcare provider's order and may not be the initial intervention for thick secretions.

4. In a client with cirrhosis admitted with ascites and jaundice, which clinical finding requires immediate intervention?

• A. Peripheral edema
• B. Confusion and altered mental status
• C. Increased abdominal girth
• D. Yellowing of the skin

Correct answer: B

Rationale: Confusion and altered mental status in a client with cirrhosis and associated ascites and jaundice are indicative of hepatic encephalopathy, a serious complication that requires immediate intervention. This condition can progress rapidly and lead to coma if not addressed promptly. Peripheral edema (choice A) and increased abdominal girth (choice C) are common manifestations of fluid retention in cirrhosis but may not require immediate intervention unless severe. Yellowing of the skin (choice D) is a classic sign of jaundice, which is already known in this client and may not necessitate immediate intervention unless associated with other concerning symptoms.

5. A client with type 2 diabetes is admitted with hyperglycemic hyperosmolar syndrome (HHS). Which clinical finding is most concerning?

• A. Serum glucose of 500 mg/dl
• B. Blood pressure of 140/90 mmHg
• C. Serum osmolarity of 320 mOsm/kg
• D. Serum pH of 7.30

Correct answer: C

Rationale: A serum osmolarity of 320 mOsm/kg is the most concerning finding in a client with hyperglycemic hyperosmolar syndrome (HHS). This level of osmolarity indicates severe dehydration and hyperosmolarity, putting the client at risk of complications like organ failure. Immediate intervention is crucial to address the dehydration and restore fluid balance. The other options, while important in the overall assessment of a client with HHS, do not directly indicate the severity of dehydration and hyperosmolarity seen with a high serum osmolarity level.

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