Nursing Elites

1. A 14-year-old male client with a spinal cord injury (SCI) at T-10 is admitted for rehabilitation. During the morning assessment, the nurse determines that the adolescent's face is flushed, his forehead is sweating, his heart rate is 54 beats/min, and his blood pressure is 198/118. What action should the nurse implement first?

• A. Determine if the urinary bladder is distended
• B. Irrigate the indwelling urinary catheter
• C. Review the temperature graph for the last day
• D. Administer an antihypertensive agent

Correct answer: A

Rationale: Autonomic dysreflexia is a potentially life-threatening emergency that can be triggered by a distended bladder in clients with spinal cord injuries at T-6 or above. The priority action is to determine if the urinary bladder is distended as this could be the cause of the symptoms observed in the adolescent. Flushing, sweating, bradycardia, and severe hypertension are classic signs of autonomic dysreflexia. Irrigating the urinary catheter, reviewing temperature graphs, or administering an antihypertensive agent are not the initial actions to take when suspecting autonomic dysreflexia.

2. Two days after an abdominal hysterectomy, an elderly female with diabetes has a syncopal episode. The nurse determines that her vital signs are within normal limits, but her blood sugar is 325 mg/dL or 18.04 mmol/L (SI). What intervention should the nurse implement first?

• A. Administer regular insulin per sliding scale
• B. Cancel the client's dinner tray
• C. Give the client 4 ounces (120 mL) of orange juice
• D. Administer the next scheduled dose of metformin

Correct answer: A

Rationale: In this case, the nurse should implement the intervention of administering regular insulin per sliding scale. High blood sugar levels, as indicated by a reading of 325 mg/dL, require insulin administration to prevent complications such as hyperglycemia. Canceling the client's dinner tray (choice B) would not address the immediate need to lower the blood sugar level. Giving the client orange juice (choice C) might further increase the blood sugar level as it contains sugar. Administering the next scheduled dose of metformin (choice D) is not appropriate as metformin is not typically used for acute management of high blood sugar levels.

3. The nurse is assessing a client with pulmonary edema who is reporting two-pillow orthopnea and paroxysmal nocturnal dyspnea. The nurse identifies rapid shallow respirations and the use of accessory muscles. Which action should the nurse include in the client’s plan of care?

• A. Administer the prescribed amiodarone (Cordarone) immediately
• B. Institute a daily fluid restriction while the client is in the hospital
• C. Perform a blood draw for serum Troponin, CK, and CK-MB levels
• D. Place the client in the Trendelenburg position to facilitate perfusion

Correct answer: A

Rationale: Administering amiodarone is appropriate if arrhythmias are present in the context of pulmonary edema, as it helps manage irregular heart rhythms. In this case, the client is experiencing symptoms related to respiratory distress, and amiodarone can address potential arrhythmias contributing to the condition. Options B and D are not directly related to managing symptoms of pulmonary edema and do not address the underlying cause of the client's distress. Option C, performing blood tests for cardiac enzymes, is important for assessing possible myocardial damage but does not directly address the immediate respiratory distress associated with pulmonary edema.

4. A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription for metformin (Glucophage) 500 mg PO twice daily. What information should the nurse include in this client’s teaching plan? (Select all that apply.)

• A. Take an additional dose for signs of hyperglycemia
• B. Recognize signs and symptoms of hypoglycemia.
• C. Report persistent polyuria to the healthcare provider.
• D. Use sliding scale insulin for finger stick glucose elevation.

Correct answer: D

Rationale: The correct answer is D. Metformin does not require additional doses for hyperglycemia, and sliding scale insulin is not typically used with metformin. It is important for the client to recognize signs and symptoms of hypoglycemia, report persistent polyuria to the healthcare provider, and take the medication with meals. Teaching the client to use sliding scale insulin for finger stick glucose elevation is not appropriate in this case because metformin is the prescribed medication, and its mechanism of action differs from insulin therapy. The client should be educated on the importance of taking metformin with meals to reduce gastrointestinal side effects and to report any persistent polyuria, which could indicate poor blood sugar control.

5. When should the nurse conduct an Allen’s test?

• A. When obtaining pulmonary artery pressures
• B. To assess for the presence of a deep vein thrombus in the leg
• C. Just before arterial blood gases are drawn peripherally
• D. Prior to attempting a cardiac output calculation

Correct answer: C

Rationale: The correct time to conduct an Allen’s test is just before arterial blood gases are drawn peripherally. This test is performed to assess the adequacy of collateral circulation in the hand before obtaining arterial blood gases. Choice A is incorrect because an Allen’s test is not specifically done when obtaining pulmonary artery pressures. Choice B is incorrect because an Allen’s test is not used to assess deep vein thrombosis. Choice D is incorrect because an Allen’s test is not done specifically before attempting a cardiac output calculation.

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