Nursing Elites

1. An unlicensed assistive personnel (UAP) reports to the nurse that a client with a postoperative wound infection has a temperature of 103°F (39.4°C), blood pressure of 90/70, pulse of 124 beats/minute, and respirations of 28 breaths/minute. When assessing the client, findings include mottled skin appearance and confusion. Which action should the nurse take first?

• A. Transfer the client to the ICU.
• B. Initiate an infusion of intravenous (IV) fluids.
• C. Assess the client's core temperature.
• D. Obtain a wound specimen for culture.

Correct answer: B

Rationale: Initiating an infusion of IV fluids is the priority action to stabilize blood pressure in a client with signs of sepsis. Intravenous fluids help maintain perfusion to vital organs and prevent further deterioration. Option A is not the immediate priority as stabilizing the client's condition can be initiated in the current setting. Option C, assessing the client's core temperature, is important but not the most critical action at this time. Option D, obtaining a wound specimen for culture, is important for identifying the causative organism but is not the first priority in managing a client with signs of sepsis.

2. The client has been managing angina episodes with nitroglycerin. Which of the following indicates the drug is effective?

• A. Decreased chest pain.
• B. Increased blood pressure.
• C. Decreased blood pressure.
• D. Decreased heart rate.

Correct answer: A

Rationale: The correct answer is A: Decreased chest pain. Nitroglycerin is a vasodilator that works by decreasing myocardial oxygen consumption, which helps to reduce chest pain caused by angina. Therefore, a reduction in chest pain is a positive indicator of the drug's effectiveness. Choices B, C, and D are incorrect because nitroglycerin does not typically increase blood pressure or heart rate; instead, it often causes a decrease in blood pressure due to vasodilation and may cause a reflex tachycardia (increased heart rate) as a compensatory response to lowered blood pressure.

3. Which of the following is a primary intervention for a patient with sepsis?

• A. Administering antibiotics
• B. Administering IV fluids
• C. Administering antipyretics
• D. Monitoring blood cultures

Correct answer: D

Rationale: Monitoring blood cultures is a primary intervention for a patient with sepsis because it helps identify the causative organism, which is crucial in guiding appropriate antibiotic therapy. Administering antibiotics (Choice A) is important in treating sepsis but is considered a secondary intervention. Administering IV fluids (Choice B) is also crucial for sepsis management to restore perfusion and hemodynamic stability. Administering antipyretics (Choice C) may help reduce fever, but it is not a primary intervention for managing sepsis.

4. Why is the combination drug trimethoprim-sulfamethoxazole (TMP-SMX) necessary?

• A. To broaden the antibacterial spectrum.
• B. To decrease bacterial resistance.
• C. To improve the taste.
• D. To minimize toxic effects.

Correct answer: B

Rationale: The correct answer is B: To decrease bacterial resistance. Trimethoprim-sulfamethoxazole (TMP-SMX) is a combination drug used to prevent bacterial resistance to sulfonamides. It works by targeting different steps in the bacterial metabolic pathway, making it harder for bacteria to develop resistance. Choice A is incorrect because the combination does not broaden the antibacterial spectrum; instead, it enhances effectiveness against specific bacteria. Choice C is incorrect as taste improvement is not the primary reason for combining these drugs. Choice D is incorrect because while combination therapy can sometimes help minimize toxic effects, the primary purpose in this case is to address bacterial resistance.

5. A marathon runner comes into the clinic and states, 'I have not urinated very much in the last few days.' The nurse notes a heart rate of 110 beats/min and a blood pressure of 86/58 mm Hg. Which action by the nurse is the priority?

• A. Give the client a bottle of water immediately.
• B. Start an intravenous line for fluids.
• C. Teach the client to drink 2 to 3 liters of water daily.
• D. Perform an electrocardiogram.

Correct answer: A

Rationale: The priority action for the nurse is to give the client a bottle of water immediately. The athlete's symptoms of decreased urination, along with a heart rate of 110 beats/min and low blood pressure of 86/58 mm Hg, indicate mild dehydration. Rehydration should begin promptly to address the dehydration. Teaching the client to drink 2 to 3 liters of water daily is a good long-term strategy but not the immediate priority. Starting an intravenous line for fluids may be necessary if oral hydration is insufficient or if the degree of dehydration is severe. Performing an electrocardiogram is not indicated at this time as the priority is addressing the dehydration.

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