Nursing Elites

1. An adolescent's mother calls the clinic because the teen is having recurrent vomiting and has become combative in the last 2 days. The mother states that the teen takes vitamins, calcium, magnesium, and aspirin. Which nursing intervention has the highest priority?

• A. Advise the mother to withhold all medications by mouth.
• B. Instruct the mother to take the teen to the emergency room.
• C. Recommend that the teen withhold food and fluids for 2 hours.
• D. Suggest that the adolescent breathe slowly and deeply.

Correct answer: B

Rationale: The correct answer is to instruct the mother to take the teen to the emergency room. The symptoms described, including recurrent vomiting and becoming combative after taking vitamins, calcium, magnesium, and aspirin, indicate a potential overdose or a serious condition. Therefore, immediate medical evaluation in the emergency room is crucial. Advising to withhold all medications by mouth (Choice A) may delay necessary treatment. Recommending to withhold food and fluids (Choice C) is not appropriate in this urgent situation. Suggesting deep breathing (Choice D) does not address the seriousness of the symptoms and the need for immediate medical attention.

2. The nurse is caring for a client with a chest tube following a pneumothorax. Which assessment finding requires immediate intervention?

• A. Oxygen saturation of 94%
• B. Subcutaneous emphysema
• C. Crepitus around the insertion site
• D. Drainage of 50 ml per hour

Correct answer: B

Rationale: Subcutaneous emphysema is the correct answer as it is most concerning in a client with a chest tube following a pneumothorax. It may indicate a pneumothorax recurrence or air leak, requiring immediate intervention to prevent complications. Oxygen saturation of 94% is acceptable and does not require immediate intervention. Crepitus around the insertion site may be a normal finding after chest tube placement and does not necessarily indicate a complication. Drainage of 50 ml per hour is within the expected range for a chest tube and does not require immediate intervention.

3. The nurse is caring for a client with acute pancreatitis who is receiving total parenteral nutrition (TPN). Which laboratory value should be monitored closely?

• A. Serum calcium
• B. Serum triglycerides
• C. Serum glucose
• D. Serum triglycerides

Correct answer: B

Rationale: Serum triglycerides should be monitored closely in a client receiving TPN as they may indicate hyperlipidemia, which is a potential complication of TPN. Monitoring serum triglycerides is essential to prevent complications such as hypertriglyceridemia. Serum calcium and glucose levels are also important to monitor in clients receiving TPN, but in this scenario, serum triglycerides take priority due to the risk of hyperlipidemia.

4. The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen. Which clinical finding requires immediate intervention?

• A. Oxygen saturation of 90%
• B. Respiratory rate of 24 breaths per minute
• C. Use of accessory muscles
• D. Inspiratory crackles

Correct answer: C

Rationale: The correct answer is C: Use of accessory muscles. In a client with COPD receiving supplemental oxygen, the use of accessory muscles is a critical finding that requires immediate intervention. This observation indicates increased work of breathing, suggesting respiratory distress. Addressing this issue promptly is crucial to prevent further respiratory compromise. Choice A, oxygen saturation of 90%, is slightly below the normal range but may not require immediate intervention unless it continues to decrease. Choice B, a respiratory rate of 24 breaths per minute, is within normal limits for an adult and does not indicate an urgent issue. Choice D, inspiratory crackles, may be present in COPD due to secretions or inflammation but do not necessitate immediate intervention unless associated with other concerning signs.

5. Following an open reduction of the tibia, the nurse notes bleeding on the client's cast. Which action should the nurse implement?

• A. Outline the area with ink and check it every 15 minutes to see if the area has increased
• B. Notify the healthcare provider immediately
• C. Apply a new cast to stop the bleeding
• D. Elevate the limb to reduce blood flow

Correct answer: A

Rationale: After an open reduction of the tibia, bleeding on the cast can be a concern. Outlining the area with ink and monitoring it every 15 minutes is the appropriate action to assess if the bleeding is worsening, indicating the need for further intervention. This action allows for close observation without disturbing the cast. Choice B is incorrect because while notifying the healthcare provider is important, immediate action is not always necessary if the bleeding is not severe. Choice C is incorrect because applying a new cast is not the standard intervention for bleeding on a cast. Choice D is incorrect because elevating the limb may not address the underlying cause of bleeding and may not be the most appropriate action at this time.

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