Nursing Elites

1. A client in the intensive care unit is being mechanically ventilated, has an indwelling urinary catheter in place, and is exhibiting signs of restlessness. Which action should the nurse take first?

• A. Review the heart rhythm on cardiac monitors
• B. Check urinary catheter for obstruction
• C. Auscultate bilateral breath sounds
• D. Give PRN dose of lorazepam (Ativan)

Correct answer: B

Rationale: When a client in the intensive care unit is mechanically ventilated, has an indwelling urinary catheter, and is restless, the priority action is to check the urinary catheter for obstruction. Restlessness in this context could be due to a blocked catheter causing discomfort or urinary retention, which needs immediate attention to prevent complications. Reviewing the heart rhythm on cardiac monitors can be important but is not the priority in this scenario. Auscultating bilateral breath sounds is also important in a ventilated client but addressing the potential immediate issue of a blocked catheter takes precedence. Giving a PRN dose of lorazepam should not be the first action without addressing the underlying cause of restlessness.

2. After receiving a report on an inpatient acute care unit, which client should the nurse assess first?

• A. The client with bowel obstruction due to a volvulus who is experiencing abdominal rigidity
• B. The client who had surgery yesterday and is experiencing a paralytic ileus with absent bowel sounds
• C. The client with an obstruction of the large intestine who is experiencing abdominal distention
• D. The client with a small bowel obstruction who has a nasogastric tube that is draining greenish fluid

Correct answer: A

Rationale: The correct answer is A. Abdominal rigidity in a client with bowel obstruction due to a volvulus indicates possible complications and requires immediate assessment. Choice B is incorrect because although a paralytic ileus with absent bowel sounds is concerning, abdominal rigidity in a client with a volvulus takes priority. Choice C is incorrect as abdominal distention, though indicative of an obstruction, is not as urgent as the sign of abdominal rigidity. Choice D is incorrect as the drainage of greenish fluid from a nasogastric tube in a client with a small bowel obstruction, while concerning, does not present as immediate a threat as the abdominal rigidity in a client with a volvulus.

3. A school nurse is called to the soccer field because a child has a nosebleed (epistaxis). In what position should the nurse place the child?

• A. Sitting up and leaning forward
• B. Reclining with head elevated
• C. Sitting up with head tilted back
• D. Lying flat on the back

Correct answer: A

Rationale: The correct position for a child with a nosebleed (epistaxis) is sitting up and leaning forward. This position helps prevent blood from flowing into the throat and causing choking. Choice B, reclining with the head elevated, and choice D, lying flat on the back, are incorrect as they can cause blood to flow backward into the throat. Choice C, sitting up with the head tilted back, is also incorrect as it can lead to blood flowing down the back of the throat and potentially into the airway.

4. What assessment data should lead the nurse to suspect that a client has progressed from HIV infection to AIDS?

• A. Enlarged and tender cervical lymph nodes
• B. Presence of low-grade fever and sore throat
• C. Recent history of recurrent pneumonia
• D. CD4 blood cell count of 300

Correct answer: C

Rationale: The correct answer is C: 'Recent history of recurrent pneumonia.' Recurrent pneumonia is a hallmark indicator of progression to AIDS in clients with HIV infection. It signifies advanced immunosuppression when the body is unable to fight off infections effectively. Enlarged and tender cervical lymph nodes (Choice A) are more indicative of local infections or inflammation rather than AIDS progression. The presence of a low-grade fever and sore throat (Choice B) may be common in various infections and are not specific to AIDS progression. While a CD4 blood cell count of 300 (Choice D) is below the normal range and indicates immunosuppression, it alone may not be sufficient to suspect progression to AIDS without other supporting indicators like opportunistic infections such as recurrent pneumonia.

5. An IV antibiotic is prescribed for a client with a postoperative infection. The medication is to be administered in 4 divided doses. What schedule is best for administering this prescription?

• A. 1000, 1600, 2200, 0400
• B. Give in equally divided doses during waking hours
• C. Administer with meals and a bedtime snack
• D. 0800, 1200, 1600, 2000

Correct answer: D

Rationale: The best schedule for administering the IV antibiotic in 4 divided doses is 0800, 1200, 1600, and 2000. This timing allows for equal spacing between doses, ensuring consistent therapeutic levels of the medication in the client's system. Choice A provides doses too close together, increasing the risk of medication errors and potential toxicity. Choice B's suggestion of giving doses during waking hours is vague and lacks specific timing, which may result in irregular dosing intervals. Choice C, administering with meals and a bedtime snack, is unrelated to the timing of the antibiotic doses and does not optimize the drug's effectiveness.

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