Nursing Elites

1. A client receiving IV antibiotics for sepsis reports itching and has a rash on the chest. What is the nurse's first action?

• A. Administer an antihistamine as prescribed.
• B. Stop the infusion and notify the healthcare provider.
• C. Slow the infusion rate and monitor the client.
• D. Administer epinephrine subcutaneously.

Correct answer: B

Rationale: The correct action for the nurse to take first when a client receiving IV antibiotics for sepsis reports itching and a rash on the chest is to stop the infusion and notify the healthcare provider. This is crucial in preventing the allergic reaction from worsening. Administering an antihistamine (choice A) may address the symptoms but does not address the primary concern of stopping the infusion. Slowing the infusion rate and monitoring the client (choice C) may not be sufficient if the reaction is severe. Administering epinephrine subcutaneously (choice D) is not the first-line intervention for this situation.

2. A client with adrenal crisis has a temperature of 102°F, heart rate of 138 bpm, and blood pressure of 80/60 mmHg. Which action should the nurse implement first?

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

Correct answer: B

Rationale: In a client with adrenal crisis presenting with a high temperature, tachycardia, and hypotension, the priority action for the nurse to implement first is to infuse an intravenous fluid bolus. This intervention aims to address the hypotension by increasing the circulating volume and improving perfusion. Obtaining an analgesic prescription (Choice A) is not the priority in this situation. Administering an oral antipyretic (Choice C) may help reduce the fever but does not address the primary issue of hypotension. Covering the client with a cooling blanket (Choice D) may help with temperature control but does not address the hemodynamic instability caused by the adrenal crisis.

3. A client with diabetes mellitus is prescribed metformin. What teaching should the nurse include?

• A. Take the medication with meals to reduce gastrointestinal upset.
• B. Monitor renal function regularly due to the risk of lactic acidosis.
• C. Avoid alcohol consumption while taking this medication.
• D. Check blood glucose levels regularly to ensure proper management.

Correct answer: B

Rationale: The correct teaching for a client prescribed metformin includes monitoring renal function regularly due to the risk of lactic acidosis, especially in clients with impaired kidney function. While taking metformin with meals can reduce gastrointestinal upset, it is not the highest priority teaching point. Avoiding alcohol is generally recommended but not the most critical teaching point in this scenario. Checking blood glucose levels regularly is important for diabetes management but not specifically related to metformin use.

4. A nurse from the maternity unit is floated to the critical care unit because of staff shortage on the evening shift. Which client would be appropriate to assign to this nurse?

• A. A client with a Dopamine drip IV with vital signs monitored every 5 minutes
• B. A client with a myocardial infarction that is free from pain and dysrhythmias
• C. A client with a tracheotomy of 24 hours in some respiratory distress
• D. A client with a pacemaker inserted this morning with intermittent capture

Correct answer: B

Rationale: In this scenario, it is more appropriate to assign a stable client, such as the one with a myocardial infarction who is free from pain and dysrhythmias, to a nurse who lacks specialized critical care experience. This client's condition is relatively stable and does not require immediate critical interventions. Choices A, C, and D involve clients with more complex and critical conditions that would be better managed by a nurse with specialized critical care training. Choice A involves a client on a Dopamine drip with frequent vital sign monitoring, Choice C has a client with a tracheotomy in respiratory distress, and Choice D describes a client with a pacemaker experiencing intermittent capture, all of which require a higher level of critical care expertise.

5. The nurse is caring for a client with a traumatic brain injury who is receiving mechanical ventilation. Which assessment finding indicates that the client may be experiencing increased intracranial pressure (ICP)?

• A. Client becomes increasingly lethargic
• B. Client's respiratory rate is 16 breaths per minute
• C. Client responds to verbal stimuli
• D. Client's pupils are equal and reactive

Correct answer: A

Rationale: Increased lethargy is a sign of worsening intracranial pressure, which can be life-threatening in clients with brain injuries. As ICP rises, it can lead to decreased level of consciousness, such as lethargy or even coma. Choices B, C, and D are not indicative of increased ICP. A normal respiratory rate, response to verbal stimuli, and equal reactive pupils do not specifically point towards increased intracranial pressure.

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