Nursing Elites

1. A patient experiences a chest wall contusion as a result of being struck in the chest with a baseball bat. The emergency department nurse would be most concerned if which finding is observed during the initial assessment?

• A. Paradoxic chest movement
• B. Complaint of chest wall pain
• C. Heart rate of 110 beats/minute
• D. Large bruised area on the chest

Correct answer: A

Rationale: Paradoxic chest movement is the most concerning finding as it indicates a potential flail chest, which can lead to severe compromise in gas exchange and rapid hypoxemia. This condition requires immediate attention to prevent respiratory distress. Complaint of chest wall pain, a slightly elevated heart rate, and a large bruised area on the chest are important assessment findings but may not immediately threaten gas exchange or respiratory function. Therefore, identifying paradoxic chest movement is critical for prompt intervention and management.

2. During an assessment of a client with cardiomyopathy, the nurse finds that the systolic blood pressure has decreased from 145 to 110 mm Hg and the heart rate has risen from 72 to 96 beats per minute, and the client complains of periodic dizzy spells. The nurse instructs the client to:

• A. Increase fluids that are high in protein
• B. Restrict fluids
• C. Force fluids and reassess blood pressure
• D. Limit fluids to non-caffeine beverages

Correct answer: D

Rationale: In this scenario, the client with cardiomyopathy is exhibiting signs of orthostatic hypotension, which is characterized by a significant drop in systolic blood pressure (>15 mm Hg) and an increase in heart rate (>15%), along with dizziness. These symptoms suggest volume depletion, inadequate vasoconstrictor mechanisms, and autonomic insufficiency. The appropriate nursing intervention in this case is to force fluids and reassess blood pressure to address the underlying issue of volume depletion and improve hemodynamic stability. Choices A, B, and D are incorrect because increasing fluids high in protein, restricting fluids, or limiting fluids to non-caffeine beverages are not appropriate actions for a client experiencing orthostatic hypotension and signs of volume depletion.

3. A newborn infant in the nursery has developed vomiting, poor feeding, lethargy, and respiratory distress, and has been diagnosed with necrotizing enterocolitis. Which of the following nursing interventions is most appropriate for this infant?

• A. Feed the infant 30 cc of sterile water
• B. Position the infant on his back
• C. Administer antibiotics as ordered
• D. Allow the infant to breastfeed

Correct answer: C

Rationale: Necrotizing enterocolitis (NEC) is a serious condition characterized by ischemic bowel, leading to gastrointestinal symptoms, lethargy, poor feeding, and respiratory distress. In the management of NEC, it is crucial to stop oral feedings, insert a nasogastric tube for decompression, and administer antibiotics as prescribed by the physician. Therefore, the most appropriate nursing intervention for an infant with NEC is to administer antibiotics as ordered. Choice A, feeding the infant sterile water, is incorrect because oral feedings should be stopped in NEC. Choice B, positioning the infant on his back, is not directly related to the treatment of NEC. Choice D, allowing the infant to breastfeed, is contraindicated in NEC as oral feedings should be ceased to prevent further complications.

4. A healthcare provider is assessing vital signs in pediatric patients. Which of the following vital signs is abnormal?

• A. 11-year-old male: 90 BPM, 22 RPM, 100/70 mmHg
• B. 13-year-old female: 105 BPM, 22 RPM, 105/50 mmHg
• C. 5-year-old male: 102 BPM, 24 RPM, 90/65 mmHg
• D. 6-year-old female: 100 BPM, 26 RPM, 90/70 mmHg

Correct answer: B

Rationale: The normal range of vital signs for pediatric patients varies with age. For 11 to 14-year-olds, the normal vital sign ranges are: Heart rate: 60-105 BPM; Respiratory rate: 12-20 RPM; Blood pressure: Systolic 85-120 mmHg, Diastolic 55-80 mmHg. The 13-year-old female in choice B has a diastolic blood pressure below the normal range, indicating hypotension. Additionally, her heart rate is at the upper limit of normal, and her respiratory rate is within normal limits. Choices A, C, and D all fall within the normal ranges for vital signs in pediatric patients.

5. How does shock typically progress?

• A. Compensated to hypotensive shock in hours and hypotensive shock to cardiac arrest in minutes
• B. Compensated to hypotensive shock in minutes and hypotensive shock to cardiac arrest in hours
• C. Hypotensive to compensated shock in hours and compensated shock to cardiac arrest in minutes
• D. Hypotensive to compensated shock in minutes and compensated shock to cardiac arrest in hours

Correct answer: A

Rationale: Shock typically progresses from a compensated state to hypotensive shock over a period of hours. In the compensated phase, the body is trying to maintain perfusion. It is crucial to identify and intervene during this phase to prevent progression to hypotensive shock, where blood pressure drops significantly. If not promptly managed, hypotensive shock can rapidly deteriorate into cardiac arrest in minutes due to inadequate perfusion to vital organs. Choices B, C, and D are incorrect as they do not follow the typical progression of shock stages as seen in clinical practice. Understanding the stages of shock and their timeframes is crucial for early recognition and appropriate intervention to prevent further deterioration.

Similar Questions