Nursing Elites

1. When assessing a client several hours after surgery, the nurse observes that the client grimaces and guards the incision while moving in bed. The client is diaphoretic, has a radial pulse rate of 110 beats/min, and a respiratory rate of 35 breaths/min. What assessment should the nurse perform first?

• A. Apical heart rate
• B. IV site and fluids
• C. Pain scale
• D. Temperature

Correct answer: C

Rationale: The client’s grimacing and guarding suggest pain; assessing the pain scale is crucial for addressing the discomfort. Pain management is a priority to ensure the client's well-being and comfort. Checking the apical heart rate, IV site and fluids, or temperature can be important but addressing the client's pain takes precedence in this scenario. The elevated pulse rate and respiratory rate could be indicative of pain, making the pain scale assessment essential to guide appropriate interventions.

2. The practical nurse (PN) is assigned to work with three registered nurses (RN) who are caring for neurologically compromised clients. The client with which change in status is best to assign to the PN?

• A. Diabetic ketoacidosis whose Glasgow Coma Scale score changed from 10 to 7
• B. Subdural hematoma whose blood pressure changed from 150/80 mmHg to 170/60 mmHg
• C. Myxedema coma whose blood pressure changed from 80/50 mmHg to 70/40 mmHg
• D. Viral meningitis whose temperature changed from 101° F (38.3 C) to 102° F (38.9C)

Correct answer: D

Rationale: The correct answer is D because viral meningitis with a slight increase in temperature is less acute and complex compared to the other conditions. This change in temperature does not indicate a critical or urgent situation requiring immediate attention or intervention beyond the scope of a practical nurse. Choices A, B, and C present more significant changes in health status such as a decrease in Glasgow Coma Scale score, an increase in intracranial pressure indicated by blood pressure changes, and a significant drop in blood pressure, respectively. These changes require closer monitoring and intervention by registered nurses due to the higher acuity and complexity of care needed for these conditions.

3. A male client with hypercholesterolemia wants to change his diet to help reduce his cholesterol levels. Which breakfast items should the nurse encourage the client to eat? (Select all that apply)

• A. Sausage patties and eggs
• B. Whole wheat toast and jam
• C. Bagels and cream cheese
• D. Blackberries and oatmeal

Correct answer: B

Rationale: The correct choices are whole wheat toast and jam (B) and blackberries and oatmeal (D). Whole wheat toast and blackberries are high in fiber, which can help lower cholesterol levels. Sausage patties and eggs (A) are high in saturated fats that can raise cholesterol levels. Bagels and cream cheese (C) are not as beneficial for cholesterol control compared to high-fiber options like whole wheat toast and blackberries.

4. When caring for a client with acute respiratory distress syndrome (ARDS), why does the nurse elevate the head of the bed 30 degrees?

• A. To reduce abdominal pressure on the diaphragm
• B. To promote retraction of the intercostal accessory muscles of respiration
• C. To promote bronchodilation and effective airway clearance
• D. To decrease pressure on the medullary center which stimulates breathing

Correct answer: A

Rationale: Elevating the head of the bed to 30 degrees is done to reduce abdominal pressure on the diaphragm, aiding in lung expansion and oxygenation. This position helps improve respiratory mechanics by allowing the diaphragm to move more effectively. Choice B is incorrect as elevating the head of the bed does not directly promote retraction of the intercostal accessory muscles of respiration. Choice C is incorrect because although elevating the head of the bed can assist with airway clearance, its primary purpose in ARDS is to decrease pressure on the diaphragm. Choice D is incorrect because reducing pressure on the medullary center is not the main goal of elevating the head of the bed; the focus is on enhancing lung function and oxygen exchange.

5. When a UAP reports to the charge nurse that a client has a weak pulse with a rate of 44 beats per minute, what action should the charge nurse implement?

• A. Instruct the UAP to count the client's apical pulse rate for sixty seconds.
• B. Determine if the UAP also measured the client's capillary refill time.
• C. Assign a practical nurse (LPN) to determine if an apical radial pulse deficit is present.
• D. Notify the health care provider of the abnormal pulse rate and pulse volume.

Correct answer: D

Rationale: The correct action for the charge nurse to implement is to notify the health care provider of the abnormal pulse rate and pulse volume. A weak pulse with bradycardia (pulse rate of 44 beats per minute) requires immediate follow-up to investigate potential underlying issues. In this situation, it is crucial to involve the healthcare provider for further assessment and intervention. Instructing the UAP to count the client's apical pulse rate for sixty seconds (Choice A) may delay necessary actions. Determining capillary refill time (Choice B) is not directly related to addressing a weak pulse, and assigning an LPN to assess an apical radial pulse deficit (Choice C) is not as urgent as involving the healthcare provider.

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