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. When caring for a client with acute respiratory distress syndrome (ARDS), why does the nurse elevate the head of the bed 30 degrees?

• A. To reduce abdominal pressure on the diaphragm
• B. To promote oxygenation by improving lung expansion
• C. To encourage use of accessory muscles for breathing
• D. To drain secretions and prevent aspiration

Correct answer: D

Rationale: Elevating the head of the bed in a client with acute respiratory distress syndrome (ARDS) is essential to drain secretions and prevent aspiration. This position helps facilitate the removal of secretions from the airways, reducing the risk of aspiration pneumonia. Choices A, B, and C are incorrect as the primary reason for elevating the head of the bed in ARDS is to assist with secretion drainage and prevent complications associated with aspiration.

3. A client with Type 1 diabetes reports feeling shaky and lightheaded. The nurse checks the client's blood glucose level and it is 60 mg/dL. What action should the nurse take first?

• A. Give the client a glucagon injection
• B. Encourage the client to eat a high-protein snack
• C. Recheck the blood glucose level in 15 minutes
• D. Administer 15 grams of a fast-acting carbohydrate

Correct answer: D

Rationale: The correct answer is D: Administer 15 grams of a fast-acting carbohydrate. The first step in treating hypoglycemia is to quickly raise the client's blood sugar level. Fast-acting carbohydrates like glucose tablets or juice are essential for this purpose. Giving a glucagon injection is typically reserved for severe hypoglycemia when the client is unable to take anything by mouth. Encouraging the client to eat a high-protein snack is not appropriate for immediate treatment of hypoglycemia. Rechecking the blood glucose level in 15 minutes is important after administering the fast-acting carbohydrate to ensure that the blood sugar has returned to a safe level.

4. The nurse is providing care for a client with severe peripheral arterial disease (PAD). The client reports a history of rest ischemia, with leg pain that occurs during the night. Which action should the nurse take in response to this finding?

• A. Elevate the legs on pillows
• B. Encourage ambulation and leg exercises
• C. Provide a heating pad for warmth
• D. Offer cold packs when the pain occurs

Correct answer: C

Rationale: Providing warmth can help dilate peripheral vessels and increase blood flow, relieving ischemic pain. In PAD, where there is already compromised blood flow, elevating the legs or applying cold therapy could worsen ischemic pain by further reducing blood flow to the extremities. Encouraging ambulation and leg exercises may be beneficial in other conditions but not suitable for clients with severe PAD experiencing rest ischemia.

5. The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client who has a seizure disorder. The client is supine, and the UAP is placing soft pillows along the side rails. What action should the nurse take?

• A. Leave the pillows in place and document the action
• B. Inform the UAP that the pillows should be removed immediately
• C. Request that the pillows be replaced with firm padding
• D. Ensure that the side rails are padded and leave the pillows

Correct answer: B

Rationale: The correct action for the nurse to take in this situation is to inform the UAP that the pillows should be removed immediately. Soft pillows along the side rails do not provide sufficient protection during a seizure. The pillows could potentially increase the risk of injury, such as hitting the head or limbs against the hard side rails. Requesting firm padding or ensuring that the side rails are padded are not as effective as removing the pillows to prevent harm to the client. Leaving the pillows in place without addressing the potential risks would not be in the best interest of the client's safety.

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