Nursing Elites

1. A client with rapid respirations and audible rhonchi is admitted to the intensive care unit because of a pulmonary embolism (PE). Low-flow oxygen by nasal cannula and weight-based heparin protocol are initiated. Which intervention is most important for the nurse to include in this client's plan of care?

• A. Evaluate blood clotting factors daily.
• B. Encourage incentive spirometry use.
• C. Administer pain medication as needed.
• D. Monitor for signs of bleeding.

Correct answer: A

Rationale: Evaluating blood clotting factors daily is crucial when a client is on heparin therapy to monitor for potential complications such as bleeding or clotting issues. This monitoring helps ensure that the heparin dose is within the therapeutic range and reduces the risk of bleeding or clotting complications. Encouraging incentive spirometry use is beneficial for preventing atelectasis and improving lung function, but in this scenario, monitoring blood clotting factors takes precedence. Administering pain medication as needed is important for the client's comfort but is not the priority in managing a pulmonary embolism. Monitoring for signs of bleeding is important due to heparin therapy, but evaluating blood clotting factors provides more specific information on the client's response to treatment.

2. When administering ceftriaxone sodium (Rocephin) intravenously to a client, which finding requires the most immediate intervention by the nurse?

• A. Stridor
• B. Nausea
• C. Headache
• D. Pruritus

Correct answer: A

Rationale: The correct answer is A: Stridor. Stridor indicates bronchospasm, a serious reaction that can compromise the client's airway. Immediate intervention is crucial to prevent further respiratory distress. Nausea, headache, and pruritus are potential side effects of ceftriaxone but are not as immediately life-threatening as airway compromise indicated by stridor.

3. A client with acute pancreatitis is admitted with severe abdominal pain. Which assessment finding should be reported to the healthcare provider immediately?

• A. Decreased bowel sounds
• B. Increased heart rate
• C. Decreased urine output
• D. Elevated blood glucose level

Correct answer: C

Rationale: Decreased urine output is concerning in a client with acute pancreatitis as it may indicate hypovolemia or renal impairment. In acute pancreatitis, decreased urine output can signify inadequate perfusion to the kidneys, leading to renal failure. While the other options are important to monitor in a client with acute pancreatitis, decreased urine output requires immediate attention to prevent further complications.

4. A 7-year-old boy is brought to the clinic because of facial edema. He reports that he has been voiding small amounts of dark, cloudy, tea-colored urine. The parents state that their son had a sore throat 2 weeks earlier, but it has resolved. After assessing the child's vital signs and weight, what intervention should the nurse implement next?

• A. Perform an otoscopic examination
• B. Measure the child's abdominal girth
• C. Collect a urine specimen for routine urinalysis
• D. Obtain a blood specimen for serum electrolytes

Correct answer: C

Rationale: Collecting a urine specimen for routine urinalysis is the next appropriate intervention. The symptoms described, including facial edema and tea-colored urine, are indicative of glomerulonephritis, a condition affecting the kidneys. A urine specimen can help assess renal function and the presence of blood and protein in the urine, which are common in glomerulonephritis. Performing an otoscopic examination (Choice A) is not relevant to the presenting symptoms. Measuring the child's abdominal girth (Choice B) is not necessary at this point as it does not directly address the urinary symptoms. Obtaining a blood specimen for serum electrolytes (Choice D) may provide information about electrolyte imbalances but is not the most appropriate initial step in this case.

5. A client with pneumonia has arterial blood gases levels at: pH 7.33; PaCO2 49 mm/Hg; HCO3 25 mEq/L; PaO2 95. What intervention should the nurse implement based on these results?

• A. Institute coughing and deep breathing protocols.
• B. Administer oxygen via nasal cannula.
• C. Prepare for intubation and mechanical ventilation.
• D. Increase IV fluids to improve hydration.

Correct answer: A

Rationale: The ABG results indicate respiratory acidosis due to an elevated PaCO2 (49 mm/Hg), indicating hypoventilation. The appropriate intervention for respiratory acidosis is to improve ventilation. Coughing and deep breathing protocols can help the client to effectively ventilate and improve gas exchange. Administering oxygen via nasal cannula (Choice B) may be necessary in respiratory distress situations, but addressing the underlying cause of hypoventilation is crucial. Intubation and mechanical ventilation (Choice C) are not the first-line interventions for uncomplicated respiratory acidosis. Increasing IV fluids (Choice D) does not directly address the respiratory acidosis present in this scenario.

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