Nursing Elites

1. While conducting a mental status examination of a newly admitted male client, the PN notes that his head is lowered, and he shows no emotion or expression when speaking. Based on these observations, what documentation should the PN include?

• A. Impaired verbalization
• B. Depressed mood
• C. Flat affect
• D. Diminished LOC

Correct answer: C

Rationale: The correct answer is C: 'Flat affect.' Flat affect refers to a lack of emotional expression, which the PN observed in the client. This observation is significant as it can provide valuable information for the client's mental health assessment and subsequent care planning. Choice A, 'Impaired verbalization,' does not capture the lack of emotional expression seen in the client. Choice B, 'Depressed mood,' may not accurately reflect the observed behavior of the client. Choice D, 'Diminished LOC,' pertains to the level of consciousness, which was not indicated as being a concern in the scenario provided.

2. While caring for a client with an AV fistula in the left forearm, the nurse observed a palpable buzzing sensation over the fistula. What action should the nurse take?

• A. Loosen the dressing of the fistula
• B. Report the presence of a bounding pulse
• C. Document that the fistula is intact
• D. Apply gentle pressure over the site

Correct answer: C

Rationale: The correct answer is C: Document that the fistula is intact. The palpable buzzing sensation (known as a thrill) over the AV fistula indicates proper functioning. It is essential for the nurse to document this finding to ensure ongoing monitoring of the fistula's status. Choices A, B, and D are incorrect. Choice A is incorrect because there is no indication to loosen the dressing. Choice B is incorrect as a bounding pulse is not associated with the palpable buzzing sensation of a thrill. Choice D is incorrect as applying pressure over the site is not necessary for this situation.

3. A post-operative client develops a sudden onset of chest pain and dyspnea. The nurse suspects a pulmonary embolism (PE). What is the priority nursing action?

• A. Administer oxygen via face mask.
• B. Elevate the client's legs.
• C. Prepare the client for immediate surgery.
• D. Notify the healthcare provider immediately.

Correct answer: A

Rationale: Administering oxygen via face mask is the priority nursing action in a post-operative client suspected of a pulmonary embolism. This intervention helps ensure adequate oxygenation while further assessments and interventions are initiated. Elevating the client's legs is not indicated for a suspected pulmonary embolism; it is more appropriate for conditions like shock. Immediate surgery is not the priority in this situation as the client is experiencing acute symptoms requiring prompt intervention. While notifying the healthcare provider is important, the immediate focus should be on providing oxygen to the client to support respiratory function.

4. A registered nurse is preparing to hang the first bag of total parenteral nutrition (TPN) solution. The client has a central line, and this is the first bag he will receive. Which of the following is the most essential piece of equipment to obtain prior to hanging the bag?

• A. Blood glucose meter
• B. Noninvasive blood pressure monitor
• C. Electronic infusion pump
• D. Urine test strips

Correct answer: C

Rationale: An electronic infusion pump is essential for administering TPN to ensure accurate delivery and avoid complications such as fluid overload or improper nutrient delivery. The pump helps regulate the flow rate precisely, which is crucial when infusing TPN. Monitoring the client's blood glucose is important but not immediately necessary before hanging the TPN bag. A noninvasive blood pressure monitor is not directly related to administering TPN and is not the most essential equipment needed for this procedure. Urine test strips are not required for administering TPN via a central line and are not essential equipment for this specific task.

5. A client is recovering from abdominal surgery and has a nasogastric (NG) tube in place. The nurse notes that the client is experiencing nausea despite the NG tube being patent. What is the nurse's best action?

• A. Increase the suction on the NG tube.
• B. Administer an antiemetic as prescribed.
• C. Irrigate the NG tube with saline.
• D. Reposition the client to the left side.

Correct answer: B

Rationale: Administering an antiemetic as prescribed is the best action for the nurse to take when a client with a patent NG tube is experiencing nausea. This intervention can help relieve nausea effectively. Increasing suction on the NG tube (Choice A) may not address the underlying cause of the nausea and could potentially lead to complications. Irrigating the NG tube with saline (Choice C) is not indicated for addressing nausea in this scenario. Repositioning the client to the left side (Choice D) is not the priority intervention for nausea in a client with a patent NG tube.

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