Nursing Elites

1. A client is admitted to the emergency room with renal calculi and is complaining of moderate to severe flank pain and nausea. The client's temperature is 100.8 degrees Fahrenheit. The priority nursing goal for this client is:

• A. Maintain fluid and electrolyte balance
• B. Control nausea
• C. Manage pain
• D. Prevent urinary tract infection

Correct answer: C

Rationale: In the scenario presented, the priority nursing goal for a client with renal calculi experiencing moderate to severe flank pain and nausea should be to manage pain. Pain management is crucial as it alleviates suffering, improves comfort, and enhances the quality of life for the client. In the case of ureteral colic from renal calculi, the cornerstone of management is effective pain control. Prompt analgesia, typically achieved with parenteral narcotics or nonsteroidal anti-inflammatory drugs (NSAIDs), is essential to provide relief and facilitate the passage of the calculi. While maintaining fluid and electrolyte balance is important in clients with renal calculi, addressing pain takes precedence as it directly impacts the client's immediate well-being. Controlling nausea and preventing urinary tract infections are also important aspects of care, but they are secondary to managing the primary concern of pain in this urgent situation.

2. A patient with a history of diabetes mellitus is on the second postoperative day following cholecystectomy. She has complained of nausea and isn't able to eat solid foods. The nurse enters the room to find the patient confused and shaky. Which of the following is the most likely explanation for the patient's symptoms?

• A. Anesthesia reaction
• B. Hyperglycemia
• C. Hypoglycemia
• D. Diabetic ketoacidosis

Correct answer: C

Rationale: In a postoperative diabetic patient who is unable to eat solid foods, the likely cause of symptoms such as confusion and shakiness is hypoglycemia. Confusion and shakiness are common manifestations of hypoglycemia. Insufficient glucose supply to the brain (neuroglycopenia) can lead to confusion, difficulty with concentration, irritability, hallucinations, focal impairments like hemiplegia, and, in severe cases, coma and death. Anesthesia reaction (Choice A) is less likely in this scenario as the patient is already on the second postoperative day. Hyperglycemia (Choice B) is unlikely given the patient's symptoms and history of not eating. Diabetic ketoacidosis (Choice D) typically presents with hyperglycemia, ketosis, and metabolic acidosis, which are not consistent with the patient's current symptoms of confusion and shakiness.

3. The nurse assesses the chest of a patient with pneumococcal pneumonia. Which finding would the nurse expect?

• A. Increased tactile fremitus
• B. Dry, nonproductive cough
• C. Hyperresonance to percussion
• D. A grating sound on auscultation

Correct answer: A

Rationale: Increased tactile fremitus over the area of pulmonary consolidation is expected with bacterial pneumonias, such as pneumococcal pneumonia. Dullness to percussion would be expected due to consolidation. Pneumococcal pneumonia typically presents with a loose, productive cough rather than a dry, nonproductive cough. Hyperresonance to percussion is not a typical finding in pneumonia and may suggest conditions like emphysema. Adventitious breath sounds such as crackles and wheezes are typical in pneumonia, but a grating sound on auscultation is more representative of a pleural friction rub rather than pneumonia.

4. While caring for a patient with respiratory disease, the nurse observes that the patient's SpO2 drops from 93% to 88% while the patient is ambulating in the hallway. What is the priority action of the nurse?

• A. Notify the healthcare provider
• B. Document the response to exercise
• C. Administer the PRN supplemental O2
• D. Encourage the patient to pace activity

Correct answer: C

Rationale: The drop in SpO2 to 88% indicates that the patient is hypoxemic and needs supplemental oxygen when exercising. Administering PRN supplemental oxygen is the priority action to correct the hypoxemia and ensure adequate oxygenation during activity. Notifying the healthcare provider can be done after stabilizing the patient's oxygen levels. Documenting the response to exercise is important but secondary to addressing the immediate hypoxemia. Encouraging the patient to pace activity is not sufficient to address the acute drop in SpO2 and provide the necessary oxygen support.

5. A client is brought into the emergency department after finishing a course of antibiotics for a urinary tract infection. The client is experiencing dyspnea, chest tightness, and agitation. Her blood pressure is 88/58, she has generalized hives over her body, and her lips and tongue are swollen. After the nurse calls for help, what is the next appropriate action?

• A. Start an IV and administer a 1-liter bolus of Lactated Ringer's solution
• B. Administer 0.3 mg of 1:1000 epinephrine IM
• C. Administer 15 mg diphenhydramine IM
• D. Monitor the client until help arrives

Correct answer: B

Rationale: A client experiencing an anaphylactic reaction will likely present with rash or hives, swelling of the lips, face, or tongue, hypotension, or dyspnea. In this scenario, the client is showing signs of anaphylaxis with dyspnea, chest tightness, hives, hypotension, and swelling of the lips and tongue. The next appropriate action would be to administer 0.3 mg of 1:1000 epinephrine intramuscularly. Epinephrine helps relax the muscles of the airway, improve breathing, and increase oxygenation, which is crucial in managing anaphylaxis. Starting an IV and administering fluids can be important but not the immediate priority. Diphenhydramine may be used as an adjunct therapy but should not delay the administration of epinephrine in the acute phase of anaphylaxis. Monitoring the client without providing immediate treatment can lead to a worsening of the anaphylactic reaction, potentially resulting in a life-threatening situation.

Similar Questions