Nursing Elites

1. During an assessment of a client with cardiomyopathy, the nurse finds that the systolic blood pressure has decreased from 145 to 110 mm Hg and the heart rate has risen from 72 to 96 beats per minute, and the client complains of periodic dizzy spells. The nurse instructs the client to:

• A. Increase fluids that are high in protein
• B. Restrict fluids
• C. Force fluids and reassess blood pressure
• D. Limit fluids to non-caffeine beverages

Correct answer: D

Rationale: In this scenario, the client with cardiomyopathy is exhibiting signs of orthostatic hypotension, which is characterized by a significant drop in systolic blood pressure (>15 mm Hg) and an increase in heart rate (>15%), along with dizziness. These symptoms suggest volume depletion, inadequate vasoconstrictor mechanisms, and autonomic insufficiency. The appropriate nursing intervention in this case is to force fluids and reassess blood pressure to address the underlying issue of volume depletion and improve hemodynamic stability. Choices A, B, and D are incorrect because increasing fluids high in protein, restricting fluids, or limiting fluids to non-caffeine beverages are not appropriate actions for a client experiencing orthostatic hypotension and signs of volume depletion.

2. A patient with leukemia is receiving chemotherapy that is known to depress bone marrow. A CBC (complete blood count) reveals a platelet count of 25,000/microliter. Which of the following actions related specifically to the platelet count should be included in the nursing care plan?

• A. Monitor for fever every 4 hours.
• B. Require visitors to wear respiratory masks and protective clothing.
• C. Consider transfusion of packed red blood cells.
• D. Check for signs of bleeding, including examination of urine and stool for blood.

Correct answer: D

Rationale: A platelet count of 25,000/microliter indicates severe thrombocytopenia, which increases the risk of bleeding. It is crucial to initiate bleeding precautions, including regularly checking for signs of bleeding such as examining urine and stool for blood. Monitoring for fever every 4 hours (Choice A) should be included for neutropenic precautions, not specifically related to platelet count. Requiring visitors to wear respiratory masks and protective clothing (Choice B) is more relevant for patients with airborne precautions. Considering transfusion of packed red blood cells (Choice C) is not indicated for low platelet count but is more appropriate for managing anemia or low hemoglobin levels.

3. Which intervention will the nurse include in the plan of care for a patient diagnosed with a lung abscess?

• A. Teach the patient to avoid using over-the-counter expectorants.
• B. Assist the patient with chest physiotherapy and postural drainage.
• C. Notify the healthcare provider immediately regarding any bloody or foul-smelling sputum.
• D. Teach about the necessity of prolonged antibiotic therapy after discharge from the hospital.

Correct answer: D

Rationale: For a patient diagnosed with a lung abscess, the priority intervention is to educate them about the importance of prolonged antibiotic therapy post-hospital discharge. Long-term antibiotic treatment is crucial for eradicating the infecting organisms in a lung abscess. Chest physiotherapy and postural drainage are not recommended for lung abscess as they can potentially spread the infection. While foul-smelling and bloody sputum are common in lung abscess, immediate notification to the healthcare provider is essential. Avoiding the use of over-the-counter expectorants is not necessary, as expectorants can be used to facilitate coughing and clearing of secretions in this condition.

4. What is the cause of meningitis that is fatal in half of the infected patients?

• A. Virus
• B. Bacteria
• C. Fungus
• D. Noninfectious agent

Correct answer: B

Rationale: Bacterial meningitis is caused by bacterial pathogens such as Streptococcus pneumoniae, Haemophilus influenzae, Listeria monocytogenes, and Neisseria meningitidis. These bacteria commonly lead to acute onset meningitis, presenting with symptoms like fever, stiff neck, and altered consciousness. The statement that bacterial meningitis is fatal in about 50% of cases is accurate, making it a serious and life-threatening condition. Viruses can also cause meningitis, but they are not typically associated with the high fatality rate seen in bacterial meningitis. Fungal meningitis is less common and usually affects individuals with weakened immune systems. Noninfectious agents do not cause meningitis.

5. A patient is admitted to the emergency department with an open stab wound to the left chest. What is the first action that the nurse should take?

• A. Position the patient so that the left chest is dependent
• B. Tape a nonporous dressing on three sides over the chest wound
• C. Cover the sucking chest wound firmly with an occlusive dressing
• D. Keep the head of the patient's bed at no more than 30 degrees elevation

Correct answer: B

Rationale: The correct initial action for a patient with an open stab wound to the chest is to tape a nonporous dressing on three sides over the chest wound. This dressing technique allows air to escape during expiration but prevents air from entering the pleural space during inspiration, helping to prevent tension pneumothorax. Placing the patient so that the left chest is dependent or covering the wound with an occlusive dressing can trap air in the pleural space, leading to tension pneumothorax. Keeping the head of the bed elevated at 30 to 45 degrees helps facilitate breathing and is not the first action to take when managing an open chest wound.

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