Nursing Elites

1. Which client should the nurse see first?

• A. Recurring crushing chest pain
• B. Needing an IV for surgery in 5 minutes
• C. Needing PCA morphine for pain control post-hysterectomy
• D. Waiting to get back to bed after sitting in a chair for 30 minutes

Correct answer: A

Rationale: The client presenting with recurring crushing chest pain should be seen first as this symptom could indicate a myocardial infarction (MI), which is a life-threatening condition requiring immediate attention. Assessing and managing potential cardiac issues take priority over other concerns like needing an IV for surgery, pain control post-hysterectomy, or assistance with mobility. While all clients require care, addressing the chest pain promptly is crucial to ensure the client's safety and well-being.

2. A nurse is instructing a patient on the order of sensations with the application of an ice water bath for a swollen right ankle. Which of the following is the correct order of sensations experienced with an ice water bath?

• A. cold, burning, aching, and numbness
• B. burning, aching, cold, and numbness
• C. aching, cold, burning, and numbness
• D. cold, aching, burning, and numbness

Correct answer: A

Rationale: The correct order of sensations experienced with an ice water bath is cold, burning, aching, and numbness, as stated by the acronym CBAN (cold, burn, ache, numbness). Option A is the correct sequence. Choice B is incorrect as it starts with burning, which typically follows the cold sensation. Choice C is incorrect as aching is usually felt after the burning sensation. Choice D is incorrect as aching usually occurs after the burning sensation.

3. What is the most common cause of acute renal failure?

• A. Shock
• B. Nephrotoxic drugs
• C. Enlarged prostate
• D. Diabetes

Correct answer: A

Rationale: The most common cause of acute renal failure is shock. In cases of shock, such as hypovolemic shock where there is low blood volume, the kidneys receive inadequate blood flow leading to acute renal failure. This can result in the kidneys starting to die within 20 minutes of low pressure. While nephrotoxic drugs can also cause acute renal failure, shock is more commonly associated with this condition. An enlarged prostate can lead to urinary retention but is not the most common cause of acute renal failure. Diabetes, on the other hand, can cause chronic kidney disease over time but is not typically the primary cause of acute renal failure.

4. When administering intravenous electrolyte solution, what precaution should the nurse take?

• A. Infuse hypertonic solutions cautiously.
• B. Mix no more than 60 mEq of potassium per liter of fluid.
• C. Prevent infiltration of calcium, which causes tissue necrosis and sloughing.
• D. Monitor the client's digitalis dosage for adjustments due to IV calcium.

Correct answer: C

Rationale: When administering intravenous electrolyte solutions, preventing the infiltration of calcium is crucial to avoid tissue necrosis and sloughing, making choice C the correct answer. Choice A is revised to 'Infuse hypertonic solutions cautiously' because hypertonic solutions should be infused cautiously to prevent adverse effects. Choice B is corrected to 'Mix no more than 60 mEq of potassium per liter of fluid' as exceeding this limit can lead to hyperkalemia. Choice D is modified to 'Monitor the client's digitalis dosage for adjustments due to IV calcium' as it is essential to monitor the digitalis dosage for potential adjustments when IV calcium is administered; however, this choice is incorrect here as it inaccurately suggests adjusting the digitalis dosage due to IV calcium, which could lead to harmful effects.

5. After a client with an Automated Internal Cardiac Defibrillator (AICD) is successfully defibrillated for Ventricular Fibrillation (VF), what should the nurse do next?

• A. Go to the client to assess for signs and symptoms of decreased cardiac output.
• B. Call the physician to inform them of the VF episode for medication adjustments.
• C. Call the 'on-call' person in the cath lab to re-charge the ICD in case of a recurrence.
• D. Document the incident on the code report form and follow up regularly.

Correct answer: A

Rationale: After a client is successfully defibrillated, the immediate priority is to assess the client for signs and symptoms of decreased cardiac output, such as altered level of consciousness, chest pain, shortness of breath, or hypotension. This assessment is crucial to determine the effectiveness of the defibrillation and the client's current hemodynamic status. Calling the physician for medication adjustments without assessing the client first could delay essential interventions. Contacting the 'on-call' person in the cath lab to re-charge the ICD is not the initial action needed after successful defibrillation. Documenting the incident is important but should not take precedence over assessing the client's immediate condition.

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