Nursing Elites

1. When a client has suffered severe burns all over his body, the most effective method of monitoring the cardiovascular system is:

• A. Cuff blood pressure.
• B. Arterial pressure.
• C. Pulmonary artery pressure.
• D. Central venous pressure.

Correct answer: D

Rationale: Central venous pressure (CVP) monitoring is the most effective method to assess fluid status and the cardiovascular system in a client with severe burns. Severe burns can lead to significant fluid shifts and hemodynamic changes, making central venous pressure monitoring crucial for guiding fluid resuscitation and managing cardiovascular stability in these patients.

2. A client with a history of coronary artery disease (CAD) is admitted with chest pain. Which intervention should the nurse implement first?

• A. Administer sublingual nitroglycerin
• B. Obtain a 12-lead electrocardiogram (ECG)
• C. Apply oxygen via nasal cannula
• D. Initiate continuous cardiac monitoring

Correct answer: C

Rationale: In a client with a history of coronary artery disease (CAD) experiencing chest pain, the priority intervention for the nurse to implement first is to apply oxygen via nasal cannula. Oxygenation is crucial to ensure adequate oxygen supply to the tissues and the heart. This intervention takes precedence over administering sublingual nitroglycerin, obtaining an ECG, or initiating continuous cardiac monitoring. While these interventions are important, ensuring adequate oxygenation is the initial priority in the management of a client with chest pain.

3. The healthcare provider plans to administer diazepam, 4 mg IV push, to a client with severe anxiety. How many milliliters should the healthcare provider administer? (Round to the nearest tenth.)

• A. 0.2 mL
• B. 0.8 mL
• C. 1.25 mL
• D. 2.0 mL

Correct answer: B

Rationale: To calculate the volume to administer, use the formula (1 mL × 4 mg) / 5 mg = 0.8 mL. The healthcare provider should administer 0.8 mL of diazepam for a dosage of 4 mg IV push. Choice A is incorrect because it results from an incorrect calculation. Choices C and D are incorrect as they do not align with the correct calculation based on the provided dosage.

4. The nurse finds a client crying behind a locked bathroom door. The client will not open the door. Which action should the nurse implement first?

• A. Instruct an unlicensed assistive personnel (UAP) to stay and keep talking to the client.
• B. Sit quietly in the client's room until the client leaves the bathroom.
• C. Allow the client to cry alone and leave the client in the bathroom.
• D. Talk to the client and attempt to find out why the client is crying.

Correct answer: D

Rationale: When encountering a client in distress, the nurse's initial response should be to communicate with the client to assess the situation and provide support. By talking to the client and attempting to find out the reason for their distress, the nurse can offer appropriate assistance and ensure the client's well-being. This action prioritizes the client's emotional needs and helps establish a therapeutic relationship, which is essential in nursing care.

5. After informing an older client that an IV line needs to be inserted, the client becomes very apprehensive, loudly expressing a dislike for all healthcare providers and nurses. How should the nurse respond?

• A. Ask the client to remain quiet so the procedure can be performed safely.
• B. Concentrate on completing the insertion as efficiently as possible.
• C. Calmly reassure the client that the discomfort will be temporary.
• D. Tell the client a joke as a means of distraction from the procedure.

Correct answer: C

Rationale: In this situation, the nurse should respond by calmly reassuring the client that the discomfort from the IV insertion will be temporary. By providing reassurance and addressing the client's concerns, the nurse can help reduce the client's apprehension and create a more supportive environment for the procedure.

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