Nursing Elites

1. The settings on a client's synchronized intermittent mandatory ventilation (SIMV) are respiratory rate 12 breaths/minute, tidal volume at 600 mL, FiO2 35%, and positive end-expiratory pressure (PEEP) 5 cm H2O. Which assessment finding necessitates immediate intervention by the nurse?

• A. Bilateral crackles in the lung bases.
• B. Low-pressure indicator alarm.
• C. Oxygen saturation of 91%.
• D. Respiratory rate of 18 breaths/minute.

Correct answer: B

Rationale: A low-pressure alarm may indicate a disconnection or leak in the system, which needs immediate intervention. Bilateral crackles in the lung bases may indicate fluid overload but do not require immediate intervention in this case. An oxygen saturation of 91% is concerning but not as urgent as a potential equipment issue. A respiratory rate of 18 breaths/minute is higher than the set rate but may not necessitate immediate intervention unless accompanied by other distress symptoms.

2. Based on the interpretation of this strip, what action should be implemented first?

• A. Call a code.
• B. Start CPR.
• C. Administer IV fluids.
• D. Apply oxygen.

Correct answer: A

Rationale: The correct answer is A: 'Call a code.' In the context of ventricular fibrillation (V-Fib), immediate defibrillation is crucial. Calling a code is the first step to activating the emergency response team, including individuals trained to provide defibrillation. Starting CPR (Choice B) may be necessary but should follow defibrillation. Administering IV fluids (Choice C) and applying oxygen (Choice D) are important interventions in cardiac arrest cases, but in V-Fib, the priority is defibrillation to restore normal heart rhythm.

3. In a disaster area, a nurse assesses an adult male with partial-thickness burns on his lower legs, approximately 10% of his lower body. Which color of triage tag should the nurse place on this client?

• A. Yellow.
• B. Black.
• C. Red.
• D. Green.

Correct answer: A

Rationale: A yellow triage tag should be placed on the client with partial-thickness burns covering 10% of his lower body. Yellow tags indicate delayed treatment, suitable for serious injuries that are not immediately life-threatening. Black tags are used for deceased individuals, red tags for immediate treatment of life-threatening injuries, and green tags for minor injuries.

4. The nurse is recording a history for a child who has been diagnosed with recurrent abdominal pain (RAP). What is a finding that is characteristic of this disorder?

• A. Morning headaches
• B. Pain for 3 consecutive months
• C. Febrile episodes in the late afternoon
• D. Diaphoresis when attacks occur

Correct answer: B

Rationale: The correct answer is B: Pain for 3 consecutive months. Recurrent abdominal pain (RAP) is characterized by abdominal pain that occurs at least once per week for at least 2 months before diagnosis. Choosing option A is incorrect since morning headaches are not a common characteristic of RAP. Option C is incorrect because febrile episodes in the late afternoon are not typically associated with RAP. Option D is incorrect as diaphoresis (excessive sweating) when attacks occur is not a common finding in RAP.

5. A young adult client, admitted to the emergency department following a motor vehicle collision, is transfused with 4 units of PRBCs. The client’s pretransfusion hematocrit is 17%. Which hematocrit value should the nurse expect the client to have after all PRBCs have been transfused?

• A. 23%
• B. 25%
• C. 27%
• D. 29%

Correct answer: D

Rationale: One unit of PRBCs typically raises the hematocrit by 3%. Since the client received 4 units, the hematocrit is expected to increase by approximately 12% (4 units x 3% per unit). Therefore, the nurse should expect the client's hematocrit to be 29% after all PRBCs have been transfused. Choices A, B, and C are incorrect as they do not account for the cumulative effect of multiple PRBC units on the hematocrit level.

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