Nursing Elites

1. An adult male is admitted to the intensive care unit because he experienced a sudden onset of sharp chest pain and shortness of breath earlier today. Following an emergent pulmonary angiogram, the client is diagnosed with a pulmonary embolism. Which intervention is most important for the nurse to include in this client’s plan of care?

• A. Monitor signs of increased bleeding
• B. Instruct on the use of incentive spirometry
• C. Observe for confusion and restlessness
• D. Administer intravenous opioids for severe pain

Correct answer: A

Rationale: In a patient diagnosed with a pulmonary embolism, the most critical intervention is to monitor for signs of increased bleeding. Pulmonary embolism treatment often involves anticoagulation therapy, which increases the risk of bleeding. Monitoring for signs of bleeding such as bruising, petechiae, hematuria, or gastrointestinal bleeding is essential to prevent complications. Instructing on the use of incentive spirometry can be beneficial for preventing pulmonary complications but is not as urgent as monitoring for bleeding. Observing for confusion and restlessness may indicate hypoxia but is not the most crucial intervention in this scenario. Administering intravenous opioids for severe pain might be necessary but is not the priority compared to monitoring for bleeding, which is directly related to the treatment for pulmonary embolism.

2. What is the primary focus of postoperative nursing care for the client with colon trauma?

• A. Monitoring for elevated coagulation studies
• B. Observation for and prevention of fistulas
• C. Monitoring for signs of hyponatremia
• D. Observation for and prevention of infection

Correct answer: D

Rationale: The correct answer is D: Observation for and prevention of infection. Postoperative nursing care for a client with colon trauma primarily focuses on preventing infections. Clients with colon trauma are at high risk for infections due to the disruption of the intestinal barrier. Monitoring for signs of infection, maintaining proper wound care, administering antibiotics as prescribed, and implementing strict aseptic techniques are essential in preventing postoperative infections. Choices A, B, and C are incorrect because elevated coagulation studies, fistulas, and hyponatremia are not the primary concerns in the immediate postoperative period for a client with colon trauma.

3. The nurse is calculating the one-minute Apgar score for a newborn male infant and determines that his heart rate is 150 beats/minute, he has a vigorous cry, his muscle tone is good with total flexion, he has quick reflex irritability, and his color is dusky and cyanotic. What Apgar score should the nurse assign to the infant?

• A. 8
• B. 9
• C. 6
• D. 7

Correct answer: A

Rationale: The correct answer is A: 8. The Apgar score is calculated based on five parameters: heart rate, respiratory effort, muscle tone, reflex irritability, and color. In this case, the infant has a good heart rate, vigorous cry, good muscle tone, and quick reflex irritability, which would total to 8. The only factor affecting the score is the cyanotic color, which could indicate potential respiratory or circulatory issues. Choices B, C, and D are incorrect as they do not reflect the overall assessment provided in the scenario.

4. A client has a blood glucose level of 70 mg/dl and reports feeling shaky and weak. What is the best initial action by the nurse?

• A. Obtain a fingerstick glucose reading
• B. Administer 15 grams of a fast-acting carbohydrate
• C. Perform a quick assessment of the client’s neuro status
• D. Provide a glass of milk and monitor the client’s symptoms

Correct answer: B

Rationale: Administering 15 grams of a fast-acting carbohydrate is the best initial action to address hypoglycemia symptoms promptly by raising blood glucose levels. This intervention is crucial to prevent further deterioration in the client's condition. Obtaining a fingerstick glucose reading is important but may delay treatment. Performing a quick assessment of the client's neuro status is secondary to addressing the immediate low blood glucose levels. Providing a glass of milk is not the recommended first-line treatment for hypoglycemia; fast-acting carbohydrates are preferred to rapidly increase blood sugar levels.

5. In a client in her third trimester of pregnancy, an S3 heart sound is auscultated. What intervention should the nurse take?

• A. Notify the healthcare provider
• B. Limit the client’s fluids
• C. Prepare the client for an echocardiogram
• D. Document in the client’s record

Correct answer: D

Rationale: An S3 heart sound can be a normal finding in pregnancy due to increased blood volume and flow. In this scenario, there is no immediate need for further interventions. Documenting this finding in the client's record is essential for tracking the client's health status and ensuring proper follow-up if needed. Notifying the healthcare provider, limiting fluids, or preparing for an echocardiogram is unnecessary as it is likely a physiological finding in pregnancy. These interventions should only be considered if other symptoms suggestive of a cardiac issue are present.

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