Nursing Elites

1. An adolescent's mother calls the clinic because the teen is having recurrent vomiting and has been combative in the last 2 days. The mother states that the teen takes vitamins, calcium, and magnesium supplements along with 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: In this scenario, the highest priority nursing intervention is to instruct the mother to take the teen to the emergency room. The symptoms of recurrent vomiting, combative behavior, and the medications (vitamins, calcium, magnesium supplements, and aspirin) taken by the teen suggest a possible overdose or serious adverse reaction. Therefore, immediate medical evaluation is crucial to assess and manage any potential toxicity or adverse effects. Advising to withhold all medications by mouth (Choice A) may delay necessary treatment. Recommending withholding food and fluids for 2 hours (Choice C) may not address the underlying cause of the symptoms. Suggesting slow and deep breathing (Choice D) is not appropriate in this urgent situation requiring immediate medical attention.

2. A client who has just returned from surgery is shivering uncontrollably. What is the best action for the nurse to take?

• A. Offer the client a warm blanket
• B. Apply warm blankets and monitor the client's temperature
• C. Place a warm blanket in the client's bed before transferring the client from the stretcher
• D. Administer a prescribed muscle relaxant

Correct answer: B

Rationale: Applying warm blankets and monitoring the client's temperature is the best action to manage postoperative shivering. Shivering after surgery can be a common response due to factors like exposure to cold, pain, or anesthesia effects. Providing warmth through blankets can help regulate the client's body temperature and alleviate shivering. Monitoring the client's temperature is essential to ensure it returns to a normal range. Option A is not as comprehensive as option B, which includes both providing warmth and monitoring the client. Option C is incorrect as it focuses on preparing the bed rather than addressing the client's immediate need for warmth. Option D is not appropriate without further assessment or prescription for a muscle relaxant to address shivering.

3. After a third hospitalization 6 months ago, a client is admitted to the hospital with ascites and malnutrition. The client is drowsy but responding to verbal stimuli and reports recently spitting up blood. What assessment finding warrants immediate intervention by the nurse?

• A. Bruises on arms and legs
• B. Round and tight abdomen
• C. Pitting edema in lower legs
• D. Capillary refill of 8 seconds

Correct answer: D

Rationale: In this situation, the client's capillary refill of 8 seconds is the assessment finding that warrants immediate intervention by the nurse. A capillary refill greater than 3 to 5 seconds indicates poor perfusion, which could be a sign of inadequate circulation and oxygenation. Checking capillary refill is a quick and useful way to assess peripheral perfusion. Bruises on arms and legs may indicate a bleeding disorder but are not as urgent as addressing poor perfusion. A round and tight abdomen could suggest ascites, which is already known in this case. Pitting edema in lower legs is a common finding in malnutrition and ascites but does not require immediate intervention as poor capillary refill does.

4. A client with a history of hypertension is admitted with a blood pressure of 200/110 mmHg. Which intervention should the nurse implement first?

• A. Administer an antihypertensive medication as prescribed.
• B. Monitor the client's urine output.
• C. Administer oxygen therapy as prescribed.
• D. Obtain an arterial blood gas (ABG) sample.

Correct answer: D

Rationale: The correct answer is to obtain an arterial blood gas (ABG) sample. In a client with severe hypertension, it is essential to assess for metabolic or respiratory acidosis which can be done through an ABG sample. Administering antihypertensive medication without assessing the acid-base status of the client can lead to potential complications. Monitoring urine output and administering oxygen therapy are important interventions but are not the priority in this situation where the focus should be on assessing acidosis.

5. The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen. Which laboratory value is most concerning?

• A. Serum sodium of 135 mEq/L
• B. Serum potassium of 4.0 mEq/L
• C. Serum bicarbonate of 18 mEq/L
• D. Serum glucose of 300 mg/dL

Correct answer: C

Rationale: A serum bicarbonate level of 18 mEq/L is most concerning in a client with COPD as it indicates metabolic acidosis, requiring immediate intervention. In COPD, patients often retain carbon dioxide, leading to respiratory acidosis. A low serum bicarbonate level suggests that the body is compensating for this respiratory acidosis by increasing bicarbonate levels to maintain balance. Therefore, a low serum bicarbonate level in this scenario is alarming. Choices A, B, and D are within normal ranges and not directly related to the acid-base imbalance seen in COPD.

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