Nursing Elites

1. A client has suspected compartment syndrome of the right lower leg. What is the nurse’s priority intervention?

• A. Elevate the right leg to reduce swelling.
• B. Loosen any restrictive dressings on the leg.
• C. Prepare the client for emergency surgery.
• D. Administer pain medication as prescribed.

Correct answer: B

Rationale: In a suspected case of compartment syndrome, the nurse's priority intervention is to loosen any restrictive dressings on the leg. This action helps to relieve pressure within the affected compartment, improve circulation, and prevent permanent damage. Elevating the leg may further increase pressure, preparing for emergency surgery is premature without proper assessment and diagnosis, and administering pain medication should come after addressing the primary issue of relieving pressure.

2. A client is admitted to the emergency department after a motor vehicle accident. The client has a Glasgow Coma Scale (GCS) score of 10. What does this score indicate?

• A. Mild impairment
• B. Moderate impairment
• C. Severe impairment
• D. Normal

Correct answer: B

Rationale: A Glasgow Coma Scale score of 10 falls into the range of moderate impairment, indicating the need for further assessment and monitoring. A GCS score of 10 suggests that the client is moderately impaired neurologically. Choices A, C, and D are incorrect because a GCS score of 10 does not indicate mild impairment, severe impairment, or normal neurological status, respectively.

3. The nurse is teaching a client about postoperative care following a total knee arthroplasty. What instruction should the nurse prioritize?

• A. Begin ambulation as soon as possible.
• B. Use continuous passive motion therapy to maintain joint mobility.
• C. Avoid putting weight on the affected leg.
• D. Apply ice packs to reduce pain and swelling.

Correct answer: B

Rationale: The correct answer is B: 'Use continuous passive motion therapy to maintain joint mobility.' Continuous passive motion therapy is crucial in postoperative care following a total knee arthroplasty as it helps prevent stiffness and maintain joint mobility. Ambulation is important but should be guided and not immediate. Avoiding putting weight on the affected leg is also essential initially to prevent complications. Applying ice packs can help reduce pain and swelling, but it is not the priority instruction for maintaining joint mobility and preventing stiffness.

4. A client with adrenal insufficiency is admitted to the ICU with acute adrenal crisis. The client's vital signs include heart rate 138 bpm and BP 80/60. What is the nurse's first intervention?

• A. Obtain an analgesic prescription.
• B. Administer an IV fluid bolus.
• C. Administer PRN antipyretic.
• D. Cover the client with a cooling blanket.

Correct answer: B

Rationale: The correct first intervention for a client with adrenal crisis and hypotension is to administer an IV fluid bolus. In adrenal crisis, the body is deficient in cortisol, leading to hypotension. Fluid resuscitation helps stabilize the blood pressure. Obtaining an analgesic prescription (Choice A) is not the priority in this situation. Administering a PRN antipyretic (Choice C) is not indicated as the client's vital signs do not suggest fever. Covering the client with a cooling blanket (Choice D) is not appropriate for addressing hypotension in adrenal crisis.

5. A client is admitted to the hospital with a diagnosis of septic shock. Which assessment finding indicates that the client's condition is deteriorating?

• A. Heart rate of 110 beats per minute
• B. Temperature of 99.5°F (37.5°C)
• C. Blood pressure of 88/52 mmHg
• D. Respiratory rate of 24 breaths per minute

Correct answer: C

Rationale: A blood pressure of 88/52 mmHg indicates hypotension, which is a sign of worsening septic shock. Hypotension can lead to organ failure and requires immediate intervention. Elevated heart rate (choice A), mild fever (choice B), and slightly increased respiratory rate (choice D) are common in septic shock and may not necessarily indicate a deteriorating condition as much as hypotension does.

Similar Questions