Nursing Elites

1. A nurse is assessing an 18-year-old female who has recently suffered a TBI. The nurse notes a slower pulse and impaired respiration. The nurse should report these findings immediately to the physician due to the possibility the patient is experiencing which of the following conditions?

• A. Increased intracranial pressure
• B. Increased function of cranial nerve X
• C. Sympathetic response to activity
• D. Meningitis

Correct answer: A

Rationale: The nurse should report the slower pulse and impaired respiration to the physician immediately as they are indicative of increased intracranial pressure (ICP) following a traumatic brain injury (TBI). These signs suggest that there may be a rise in pressure within the skull, which can be a life-threatening condition requiring urgent intervention. Options B and C are unlikely in this scenario as they do not correlate with the symptoms presented. Meningitis (Option D) typically presents with different signs and symptoms, such as fever, headache, and neck stiffness, which are not described in the patient's case.

2. What is the best lab test to diagnose disseminated intravascular coagulation (DIC)?

• A. platelet count
• B. prothrombin time (PT)
• C. partial thromboplastin time (PTT)
• D. D-dimer

Correct answer: D

Rationale: The best lab test to diagnose disseminated intravascular coagulation (DIC) is the D-dimer test. In DIC, numerous small clots form throughout the body and are rapidly broken down. D-dimer measures a specific fibrin split product and is the most specific test for DIC. Platelet count (Choice A) is decreased in DIC due to consumption, but it is not specific for diagnosing DIC. Prothrombin time (PT - Choice B) and partial thromboplastin time (PTT - Choice C) are both elevated in DIC because clotting factors have been used up, but they are not specific for DIC as they can be elevated in other conditions as well.

3. A 3-day post-operative client with a Left Knee Replacement is complaining of being chilled and nauseated. Her TPR is 100.4-94-28 and Blood Pressure is 146/90. What is the nurse's best action?

• A. Call the surgeon immediately.
• B. Administer Extra Strength Tylenol per orders.
• C. Assess the surgical site.
• D. Offer extra blankets and increase fluids.

Correct answer: A

Rationale: The correct answer is to call the surgeon immediately. The client's symptoms of being chilled and nauseated, along with an elevated temperature (100.4�F), could indicate an infection following the knee replacement surgery. In this scenario, prompt action is crucial to prevent any potential complications. Calling the surgeon allows for further assessment, possible diagnostic tests, and appropriate interventions to be initiated. Administering Tylenol or offering blankets and fluids may temporarily alleviate symptoms but do not address the underlying issue of a potential infection. Assessing the surgical site is important but not as urgent as involving the surgeon in this situation.

4. Assessment of the client with an arteriovenous fistula for hemodialysis should include:

• A. inspection for visible pulsations.
• B. palpation of thrill.
• C. percussion for dullness.
• D. auscultation of blood pressure.

Correct answer: B

Rationale: The correct answer is to palpate for a thrill. A thrill should be present in a functioning arteriovenous fistula (AVF) and indicates good blood flow. The client should be educated to check for this sensation daily at home to monitor the AVF's patency. Visible pulsations are not typically observed in an AVF. Percussion for dullness does not provide relevant information about the AVF. Auscultation of blood pressure is not a standard practice in assessing an AVF. However, auscultation of the AVF for a bruit, a sound indicating turbulent blood flow, is crucial in evaluating the AVF's patency.

5. The nurse should plan to evaluate the earliest onset of effectiveness of nitroglycerin (Nitrostat) sublingual (SL) within what time frame?

• A. 15 seconds
• B. 3 minutes
• C. 5 minutes
• D. 15 minutes

Correct answer: B

Rationale: The onset of action for Nitrostat SL is 1 to 3 minutes. Therefore, the nurse should plan to evaluate the earliest onset of effectiveness within 3 minutes after administering the medication. Option A, 15 seconds, is too short of a time frame for the onset of action of Nitrostat. Option C, 5 minutes, is slightly delayed compared to the typical onset time. Option D, 15 minutes, is too long to wait for evaluating the effectiveness of Nitrostat sublingual administration.

Similar Questions