Nursing Elites

1. When caring for a client with traumatic brain injury (TBI) who had a craniotomy for increased intracranial pressure (ICP), the nurse assesses the client using the Glasgow Coma Scale (GCS) every two hours. For the past 8 hours, the client's GCS score has been 14. What does this GCS finding indicate about the client?

• A. Neurologically stable without indications of increased ICP.
• B. At risk for neurological deterioration.
• C. Experiencing mild cognitive impairment.
• D. In need of immediate medical intervention.

Correct answer: A

Rationale: A GCS score of 14 indicates that the client is neurologically stable without indications of increased ICP. It suggests that the client's neurological status is relatively intact, with only mild impairment, if any. This finding reassures the nurse that there are currently no signs of deterioration or immediate need for intervention. Choice B is incorrect because a GCS score of 14 does not necessarily indicate immediate risk for neurological deterioration. Choice C is incorrect as mild cognitive impairment is not typically inferred from a GCS score of 14. Choice D is incorrect as immediate medical intervention is not warranted based on a GCS score of 14 without other concerning symptoms.

2. The nurse is caring for a client with acute kidney injury (AKI) secondary to gentamicin therapy. The client's serum blood potassium is elevated. Which finding requires immediate action by the nurse?

• A. Anuria for the last 12 hours.
• B. Tachycardia and hypotension.
• C. Decreased urine output.
• D. Elevated blood urea nitrogen (BUN) levels.

Correct answer: A

Rationale: The correct answer is A. Anuria for the last 12 hours. Anuria, the absence of urine output, indicates complete kidney failure and is a medical emergency that requires immediate attention. In acute kidney injury (AKI), the kidneys are unable to filter waste from the blood effectively, leading to a buildup of toxins and electrolyte imbalances like elevated blood potassium levels. Tachycardia and hypotension (choice B) can be seen in AKI but do not reflect the urgency of addressing anuria. Decreased urine output (choice C) is concerning but not as critical as the absence of urine production. Elevated blood urea nitrogen (BUN) levels (choice D) are indicative of kidney dysfunction but do not demand immediate action as anuria does.

3. A client with a history of atrial fibrillation is prescribed warfarin (Coumadin). Which laboratory value should the nurse monitor closely?

• A. Prothrombin time (PT)
• B. Hemoglobin level
• C. International Normalized Ratio (INR)
• D. Serum sodium level

Correct answer: C

Rationale: The correct answer is C, International Normalized Ratio (INR). The INR should be closely monitored in a client prescribed warfarin (Coumadin) to assess the effectiveness and safety of anticoagulation therapy. Monitoring the INR helps ensure that the client is within the therapeutic range for anticoagulation, reducing the risk of bleeding or clotting complications. Prothrombin time (A) is used to calculate the INR and monitor the effectiveness of warfarin therapy. Hemoglobin level (B) is important but not the primary lab value to monitor when a client is on warfarin. Serum sodium level (D) is not directly related to monitoring warfarin therapy.

4. After checking the fingerstick glucose at 1630, what action should be implemented?

• A. Notify the healthcare provider.
• B. Administer 8 units of insulin aspart SubQ.
• C. Give an IV bolus of Dextrose 50% 50 ml.
• D. Perform quality control on the glucometer.

Correct answer: B

Rationale: Administering insulin aspart (rapid-acting insulin) is the appropriate action to manage the elevated glucose level of 1630. Choice A, notifying the healthcare provider, is not the immediate action needed for this glucose level. Choice C, giving an IV bolus of Dextrose 50%, would exacerbate hyperglycemia instead of treating it. Choice D, performing quality control on the glucometer, is not relevant to the management of the patient's glucose level at this time.

5. Which class of drugs is the only source of a cure for septic shock?

• A. Antihypertensives
• B. Anti-infectives
• C. Antihistamines
• D. Anticholesteremics

Correct answer: B

Rationale: The correct answer is B: Anti-infectives. Anti-infective agents, such as antibiotics, are essential in treating septic shock as they can eliminate bacteria and halt the progression of the condition by stopping the production of endotoxins. Antihypertensives (Choice A) are used to lower blood pressure, antihistamines (Choice C) are used to treat allergic reactions, and anticholesteremics (Choice D) are used to lower cholesterol levels. However, none of these drug classes directly address the bacterial infection that underlies septic shock.

Similar Questions