Nursing Elites

1. An adult suffered burns to the face and chest resulting from a grease fire. On admission, the client was intubated, and a 2-liter bolus of normal saline was administered IV. Currently, the normal saline is infusing at 250 ml/hour. The client’s heart rate is 120 beats/minute, blood pressure is 90/50 mmHg, respirations are 12 breaths/minute over the ventilated 12 breaths for a total of 24 breaths/minute, and the central venous pressure (CVP) is 4 mm H2O. Which intervention should the nurse implement?

• A. Increase the rate of normal saline infusion
• B. Infuse an additional bolus of normal saline
• C. Lower the head of the bed to a recumbent position
• D. Bring a tracheostomy tray to the bedside

Correct answer: B

Rationale: The correct intervention is to infuse an additional bolus of normal saline. The client's presentation with a heart rate of 120 beats/minute, hypotensive blood pressure of 90/50 mmHg, and low CVP of 4 mm H2O indicates hypovolemic shock. Administering more normal saline can help in restoring intravascular volume and improving perfusion. Increasing the rate of normal saline infusion (Choice A) is not the best choice as it may lead to fluid overload. Lowering the head of the bed to a recumbent position (Choice C) could worsen hypotension by reducing venous return. Bringing a tracheostomy tray to the bedside (Choice D) is not a priority at this time as the client is already intubated, and the immediate concern is addressing the hypovolemia.

2. Following morning care, a client with C-5 spinal cord injury who is sitting in a wheelchair becomes flushed and complains of a headache. Which intervention should the nurse implement first?

• A. Check for any kinks or obstructions in the client’s Foley tubing
• B. Assess the client’s blood pressure every 15 minutes
• C. Administer a prescribed PRN dose of hydralazine (Apresoline)
• D. Educate the client on recognizing symptoms of dysreflexia

Correct answer: B

Rationale: In a client with a C-5 spinal cord injury experiencing flushing and a headache, the priority intervention is to assess the client's blood pressure every 15 minutes. These symptoms could indicate autonomic dysreflexia, a potentially life-threatening condition. Assessing the blood pressure is crucial to identify and address this emergency situation promptly. Checking for kinks or obstructions in the Foley tubing (Choice A) is important but not the priority in this scenario. Administering hydralazine (Choice C) without knowing the blood pressure could be harmful as it may lead to a sudden drop in blood pressure. Educating the client on recognizing symptoms of dysreflexia (Choice D) is important for long-term management but is not the immediate action needed in this acute situation.

3. Which client should the nurse assess frequently because of the risk for overflow incontinence?

• A. A client who is bedfast, with increased serum BUN and creatinine levels
• B. A client with hematuria and decreasing hemoglobin and hematocrit levels
• C. A client who has a history of frequent urinary tract infections
• D. A client who is confused and frequently forgets to go to the bathroom

Correct answer: A

Rationale: The correct answer is A. Bedfast clients with increased serum BUN and creatinine levels are at high risk for overflow incontinence. This occurs due to decreased bladder function and reduced ability to sense bladder fullness, leading to the bladder overfilling and leaking urine. Choice B describes symptoms related to possible urinary tract infections or renal issues, but these do not directly indicate overflow incontinence. Choice C, a history of frequent urinary tract infections, may suggest other urinary issues but not specifically overflow incontinence. Choice D, a confused client who forgets to go to the bathroom, is more indicative of functional incontinence rather than overflow incontinence.

4. A 60-year-old male with type 2 diabetes mellitus tells the nurse that he is going to join a gym and start working out. Which information is most important for the nurse to obtain?

• A. Recent serum cholesterol levels
• B. Presence of calf pain during exercise
• C. Average weight gain or loss in the last year
• D. Exercise tolerance test with EKG results

Correct answer: B

Rationale: The most important information for the nurse to obtain in this scenario is the presence of calf pain during exercise. Calf pain during exercise could indicate peripheral vascular issues, such as peripheral artery disease, which is crucial to address before starting an exercise program. High cholesterol levels (choice A) may be important but are not as immediately relevant as assessing for peripheral vascular issues. Average weight gain or loss (choice C) may provide some insight into the patient's overall health status but is not as critical as assessing for potential vascular complications. An exercise tolerance test with EKG results (choice D) may be valuable in assessing cardiovascular fitness but is not as crucial as evaluating for peripheral vascular issues given the patient's symptoms.

5. The nurse receives change of shift report on a group of clients for the upcoming shift. A client with which condition requires the most immediate attention by the nurse?

• A. Gunshot wound three hours ago with dark drainage of 2 cm on the dressing
• B. Mastectomy 2 days ago with 50 ml bloody drainage in the Jackson-Pratt drain
• C. Collapsed lung after a fall 8 hours ago with 100 ml blood in the chest tube collection container
• D. Abdominal-perineal resection 2 days ago with no drainage on dressing and fever and chills

Correct answer: C

Rationale: A collapsed lung with significant blood accumulation requires immediate attention to prevent respiratory compromise. Option A may also require attention, but the immediate threat to airway and breathing in option C takes precedence over the others. Option B has expected drainage after a mastectomy, and option D's fever and chills, while concerning, do not pose an immediate life-threatening risk as in option C.

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