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. A man calls the hospital and asks to talk with the nurse about his girlfriend who was extremely intoxicated on admission and is receiving services for detoxification. He knows that she is in the facility and asks the nurse about her condition. What is the nurse's best response?

• A. ''I can only report that the client is in satisfactory condition.''
• B. ''Let me give you the telephone number for her room.''
• C. ''I cannot acknowledge if a client is here or not.''
• D. ''I will have the nurse who is working with her call you.''

Correct answer: C

Rationale: The nurse must adhere to confidentiality rules and cannot confirm the presence or condition of the client. Choice A is incorrect because disclosing the client's condition breaches confidentiality. Choice B is wrong as it reveals the client's room number, which is also a breach of confidentiality. Choice D is not the best response as it involves sharing information about the client without verifying the caller's identity or relationship to the client.

3. Two hours after delivering a 9-pound infant, a client saturates a perineal pad every 15 minutes. Although an IV containing Pitocin is infusing, her uterus remains boggy, even with massage. The healthcare provider prescribes methylergometrine maleate (Methergine) 0.2 mg IM STAT. Which complication should the nurse be alert to this client developing?

• A. Decreased respiratory rate
• B. Increased temperature
• C. Tachycardia
• D. Hypertension

Correct answer: D

Rationale: The correct answer is D: Hypertension. Methylergometrine maleate (Methergine) is a medication used to prevent or control postpartum hemorrhage by causing uterine contractions. One of the potential side effects is hypertension. Therefore, the nurse should closely monitor the client's blood pressure after administering Methergine. Choices A, B, and C are incorrect because Methergine is not known to cause decreased respiratory rate, increased temperature, or tachycardia.

4. A college student brings a dorm roommate to the campus clinic because the roommate has been talking to someone who is not present. The client tells the nurse that her voices are saying, “Kill, Kill.” What question should the nurse ask the client next?

• A. When did these voices begin?
• B. Are you planning to obey the voices?
• C. Have you taken any hallucinogens?
• D. Do you believe the voices are real?

Correct answer: B

Rationale: Assessing whether the client has a plan to act on the voices is critical for evaluating the risk of harm. Asking if the client is planning to obey the voices helps determine the immediate safety concerns. While understanding when the voices began could provide insight into the situation, assessing the intent to act on them is more urgent. Asking about hallucinogen use may be relevant but does not address the immediate safety issue. Inquiring about the client's belief in the reality of the voices is important but does not address the immediate risk of harm.

5. The nurse identifies the presence of clear fluid on the surgical dressing of a client who just returned to the unit following lumbar spinal surgery. What action should the nurse implement immediately?

• A. Change the dressing using a compression bandage
• B. Test fluid on the dressing for glucose
• C. Document the findings in the electronic medical record
• D. Mark drainage area with a pen and continue to monitor

Correct answer: B

Rationale: The correct action for the nurse to implement immediately upon identifying clear fluid on the surgical dressing post-lumbar surgery is to test the fluid for glucose. Clear fluid could indicate cerebrospinal fluid (CSF) leakage, and testing for glucose can help confirm this. Changing the dressing using a compression bandage (Choice A) without further assessment could lead to complications. Documenting the findings (Choice C) is important but not as immediate as confirming the presence of CSF. Marking the drainage area with a pen and monitoring (Choice D) does not address the need for immediate confirmation of CSF leakage.

Similar Questions