Nursing Elites

1. A 59-year-old male client is brought to the emergency room where he is assessed to have a Glasgow Coma Scale of 3. Based on this assessment, how should the nurse characterize the client's condition?

• A. The client is experiencing increased intracranial pressure
• B. He has a good prognosis for recovery
• C. This client is conscious, but is not oriented to time and place
• D. He is in a coma, and has a very poor prognosis

Correct answer: D

Rationale: A Glasgow Coma Scale of 3 indicates severe neurological impairment, suggesting a deep coma or even impending death. This client's condition is critical, and he has a very poor prognosis. Choice A is incorrect because a GCS of 3 does not directly indicate increased intracranial pressure. Choice B is incorrect as a GCS of 3 signifies a grave neurological status. Choice C is incorrect as a GCS of 3 represents a state of unconsciousness rather than being conscious but disoriented.

2. A female client on the mental health unit tells the nurse that her roommate is sitting on the bathroom floor with superficial cuts on her wrists. The nurse cleans and assesses the client's wrists and asks what happened. She doesn't respond. What should the nurse do next?

• A. Find supplies to put a dressing on the client's wrists
• B. Take the client to a room for supervision by staff
• C. Call the healthcare provider to report the client's behavior
• D. Go find a staff member to stay in the room with the client

Correct answer: B

Rationale: In this situation, the nurse should prioritize the safety of the client. Taking the client to a room for supervision by staff is crucial to ensure immediate safety and further assessment of the client's condition. While cleaning and assessing the client's wrists are important, ensuring ongoing safety and monitoring by staff is the priority. Calling the healthcare provider at this moment may cause delays in providing immediate assistance. Finding supplies to put a dressing on the client's wrists can wait until the client is in a safe environment. Therefore, option B is the best course of action to address the client's safety needs promptly.

3. Which nursing diagnosis has the highest priority when planning care for a client in cardiogenic shock?

• A. Risk for imbalanced body temperature
• B. Excess fluid volume
• C. Fatigue
• D. Ineffective Tissue Perfusion

Correct answer: D

Rationale: In cardiogenic shock, the priority nursing diagnosis is Ineffective Tissue Perfusion. This diagnosis indicates that the client is not receiving adequate oxygenated blood to tissues, putting vital organs at risk. Addressing ineffective tissue perfusion is crucial to prevent organ damage and ensure the client's survival. The other options, such as 'Risk for imbalanced body temperature,' 'Excess fluid volume,' and 'Fatigue,' are important but secondary to the immediate threat of inadequate tissue perfusion in cardiogenic shock.

4. A client with a history of seizures is being discharged with a prescription for phenytoin (Dilantin). Which instruction should the nurse provide this client?

• A. Take the medication with meals
• B. Avoid alcohol while taking this medication
• C. Limit sodium intake
• D. Take the medication at bedtime

Correct answer: B

Rationale: The correct instruction is to advise the client to avoid alcohol while taking phenytoin. Alcohol can interact with phenytoin, making it less effective and leading to increased side effects. Taking the medication with meals (Choice A) may help reduce gastrointestinal upset but is not the most crucial instruction for this medication. Limiting sodium intake (Choice C) is not directly related to phenytoin therapy. Taking the medication at bedtime (Choice D) is not a standard instruction for phenytoin administration.

5. In preparing to administer a scheduled dose of intravenous furosemide (Lasix) to a client with heart failure, the nurse notes that the client's B-Type Naturetic peptide (BNP) is elevated. What action should the nurse take?

• A. Measure the client's oxygen saturation before taking further action
• B. Administer a PRN dose of nitroglycerin (Nitrostat)
• C. Administer the dose of furosemide as scheduled
• D. Hold the dose of furosemide until contacting the healthcare provider

Correct answer: C

Rationale: Administering the scheduled dose of furosemide is appropriate when a client with heart failure has an elevated BNP level. BNP elevation indicates fluid overload, and furosemide is a diuretic that helps in reducing excess fluid. Measuring the client's oxygen saturation (Choice A) is not directly related to addressing fluid overload. Administering nitroglycerin (Choice B) is not indicated for managing elevated BNP levels. Holding the furosemide dose (Choice D) would delay appropriate treatment for fluid overload.

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