Nursing Elites

1. A client with a traumatic brain injury becomes progressively less responsive to stimuli. The client has a 'Do Not Resuscitate' prescription, and the nurse observes that the unlicensed assistive personnel (UAP) has stopped turning the client from side to side as previously scheduled. What action should the nurse take?

• A. Advise the UAP to resume positioning the client on schedule
• B. Notify the healthcare provider
• C. Document the UAP's actions
• D. Discuss the situation with the client’s family

Correct answer: A

Rationale: Continuing to turn the client is crucial to prevent complications such as pressure ulcers, even if the client is less responsive. Advising the UAP to resume positioning the client on schedule is the most appropriate action in this situation. This action ensures that the client's care needs are met and helps prevent potential complications. Notifying the healthcare provider or documenting the UAP's actions may delay the necessary care for the client. Discussing the situation with the client's family is important but addressing the immediate care need of turning the client takes priority.

2. An adult male who fell from a roof and fractured his left femur is admitted for surgical stabilization after having a soft cast applied in the emergency department. Which assessment finding warrants immediate intervention by the nurse?

• A. Weak palpable distal pulses
• B. Pain at the fracture site
• C. Mild swelling of the leg
• D. Bruising around the fracture site

Correct answer: A

Rationale: In a patient with a fractured femur, weak palpable distal pulses can indicate compromised circulation to the lower extremity. This finding suggests a potential vascular compromise that requires immediate intervention to prevent further complications like compartment syndrome or ischemia. Pain at the fracture site, mild swelling of the leg, and bruising around the fracture site are expected following such an injury and surgical stabilization, and while they should be monitored, they do not require immediate intervention like addressing compromised circulation.

3. A 75-year-old female client is admitted to the orthopedic unit following an open reduction and internal fixation of a hip fracture. On the second postoperative day, the client becomes confused and repeatedly asks the nurse where she is. What information is most important for the nurse to obtain?

• A. History of alcohol use
• B. Current medication list
• C. Baseline cognitive status
• D. Family history of dementia

Correct answer: A

Rationale: The correct answer is A: History of alcohol use. In this scenario, obtaining the history of alcohol use is crucial as it could indicate withdrawal, which might explain the client's confusion. Alcohol withdrawal can lead to symptoms such as confusion, agitation, and disorientation. While knowing the current medication list (choice B) is important for overall patient care, in this case, alcohol withdrawal is a more likely cause of the confusion. Baseline cognitive status (choice C) is valuable for comparison but may not directly explain the sudden confusion. Family history of dementia (choice D) is less relevant in this acute situation compared to the potential immediate impact of alcohol withdrawal.

4. A client with type 2 diabetes is admitted with hyperglycemic hyperosmolar syndrome (HHS). Which clinical finding is most concerning to the nurse?

• A. Serum glucose of 500 mg/dL
• B. Blood pressure of 140/90 mmHg
• C. Serum osmolarity of 320 mOsm/kg
• D. Serum pH of 7.30

Correct answer: C

Rationale: A serum osmolarity of 320 mOsm/kg is the most concerning finding in a client with hyperglycemic hyperosmolar syndrome (HHS) as it indicates severe dehydration and hypertonicity. This high serum osmolarity level can lead to neurological complications and requires immediate intervention to prevent further deterioration. Serum glucose levels, blood pressure, and serum pH are important parameters to monitor in HHS, but a significantly elevated serum osmolarity poses a higher risk of complications and warrants urgent attention. High serum glucose levels, like 500 mg/dL, are expected in HHS but do not directly indicate the severity of dehydration. Blood pressure of 140/90 mmHg is within normal limits and may not be directly related to the acute complications of HHS. A serum pH of 7.30 suggests acidosis, which is important to address but may not be as immediately concerning as severe dehydration indicated by high serum osmolarity.

5. The nurse provides feeding tube instructions to the wife of a client with end-stage cancer. The client's wife performs a return demonstration correctly but begins crying and tells the nurse, 'I just don't think I can do this every day.' The nurse should direct further teaching strategies toward which learning domain?

• A. Cognitive.
• B. Affective.
• C. Comprehension.
• D. Psychomotor.

Correct answer: B

Rationale: The correct answer is B: Affective. The affective domain involves feelings and emotions, which are significant factors in the wife’s ability to cope and perform the required care. In this scenario, the wife's emotional response indicates a need for further support and teaching strategies to address her emotional concerns and build her confidence. Choices A, C, and D are incorrect because the issue at hand is not purely cognitive (knowledge), comprehension (understanding), or psychomotor (physical skills), but rather an emotional response that falls under the affective domain.

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