Nursing Elites

1. While caring for a client with an arterial line, which of the following actions should the nurse take?

• A. Level the transducer with the client's phlebotomy site
• B. Flush the arterial line every 8 hours
• C. Obtain a blood sample for arterial blood gases
• D. Keep the client's hand elevated above the heart level

Correct answer: C

Rationale: Obtaining arterial blood gases is a crucial nursing action when caring for a client with an arterial line. This procedure helps assess the client's oxygenation status and acid-base balance accurately. Leveling the transducer with the client's phlebotomy site (A) is important for accurate pressure measurements, but it is not the primary action in this scenario. Flushing the arterial line every 8 hours (B) is a routine maintenance procedure and not the immediate priority. Keeping the client's hand elevated above the heart level (D) is a good practice to prevent swelling, but it is not directly related to the arterial line care in this case.

2. Four clients present to the emergency department. The nurse should plan to see which of the following clients first?

• A. A 6-year-old client with a dislocated left shoulder
• B. A 26-year-old client with sickle cell disease and severe joint pain
• C. A 76-year-old client who is confused, febrile, and has foul-smelling urine
• D. A 50-year-old client with slurred speech, disorientation, and headache

Correct answer: D

Rationale: The correct answer is D. A client presenting with symptoms of a stroke, such as slurred speech, disorientation, and headache, requires immediate attention due to the possibility of a neurological emergency. Choices A, B, and C, although concerning, do not present with symptoms as urgent as those of a potential stroke. Dislocated shoulder, sickle cell disease with joint pain, and confusion with febrile illness can be addressed after ensuring the client with stroke-like symptoms receives prompt evaluation and intervention.

3. A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The nurse obtained a verbal prescription for restraints. Which of the following actions should the nurse take?

• A. Request a renewal of the prescription every 8 hours.
• B. Check the client's peripheral pulse rate every 30 minutes.
• C. Obtain a prescription for restraint within 4 hours.
• D. Document the client's condition every 15 minutes.

Correct answer: C

Rationale: When caring for a client with bipolar disorder experiencing acute mania and having obtained a verbal prescription for restraints, the nurse must ensure to obtain a formal written prescription for restraint within 4 hours. This is crucial to maintain the safety and proper care of the client. Choices A, B, and D are incorrect because renewing the prescription every 8 hours, checking pulse rate every 30 minutes, and documenting the client's condition every 15 minutes do not address the immediate need for a formal restraint prescription within 4 hours to manage the client's acute mania effectively.

4. A nurse is caring for a client who has schizophrenia. Which of the following findings should the nurse expect?

• A. Decreased level of consciousness
• B. Inability to identify common objects
• C. Preoccupation with somatic disturbances
• D. Poor problem-solving ability

Correct answer: B

Rationale: The correct answer is B: Inability to identify common objects. Clients with schizophrenia often experience cognitive deficits, such as difficulty in identifying common objects. This can be attributed to impairments in perception and cognition. Choices A, C, and D are not typically associated with schizophrenia. Decreased level of consciousness is more indicative of conditions like head injuries or metabolic disturbances. Preoccupation with somatic disturbances is commonly seen in somatic symptom disorders, not schizophrenia. Poor problem-solving ability is a characteristic of conditions affecting executive functioning like dementia, rather than schizophrenia.

5. A nurse is caring for a client who has a prescription for furosemide. The nurse should monitor the client for which of the following electrolyte imbalances?

• A. Hypernatremia
• B. Hypokalemia
• C. Hypercalcemia
• D. Hypomagnesemia

Correct answer: B

Rationale: The correct answer is B: Hypokalemia. Furosemide, a loop diuretic, can cause potassium loss leading to hypokalemia. Monitoring potassium levels is crucial as low potassium can result in various complications like cardiac dysrhythmias. Choices A, C, and D are incorrect. Hypernatremia is high sodium levels, which are not typically associated with furosemide use. Hypercalcemia is elevated calcium levels and hypomagnesemia is low magnesium levels, which are not the primary electrolyte imbalances associated with furosemide.

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