Nursing Elites

1. Following the evacuation of a subdural hematoma, an older adult develops an infection. The client is transferred to the neuro intensive care unit with a temperature of 101.8 F (39.3 C) axillary, pulse of 180 beats/minute, and a blood pressure of 90/60 mmHg. What is the priority intervention to include in this client’s plan of care?

• A. Confusion
• B. Check neuro vital signs every 4 hours.
• C. Maintain intravenous access.
• D. Keep the suture line clean and dry.

Correct answer: C

Rationale: The priority intervention for the client in this scenario is to maintain intravenous (IV) access. Given the client's condition with infection, elevated temperature, tachycardia, and hypotension, it is crucial to ensure IV access for administering antibiotics, fluids, and other medications promptly. This can help manage the infection, stabilize hemodynamics, and support the client's hydration and medication needs. Checking neuro vital signs, although important, is secondary to addressing the immediate need for IV access. Keeping the suture line clean and dry is important for wound care but not the priority when dealing with a systemic infection and hemodynamic instability.

2. Based on the information provided in this client’s medical record during labor, which intervention should the nurse implement?

• A. Apply oxygen at 10 L per minute via mask
• B. Stop the oxytocin infusion
• C. Turn the client to the right lateral position
• D. Continue monitoring the progress of labor

Correct answer: C

Rationale: Turning the client to the right lateral position is essential as it can improve fetal oxygenation and uterine blood flow, promoting better labor outcomes. This intervention helps relieve pressure on blood vessels, enhancing blood flow to the placenta and improving oxygen supply to the fetus. Applying oxygen at a specific rate may not address the underlying issue of compromised blood flow and oxygenation. Stopping the oxytocin infusion is not the priority unless medically indicated as it can affect labor progression. While monitoring the progress of labor is important, actively addressing the compromised fetal oxygenation and uterine blood flow by changing the client's position takes precedence in this scenario.

3. What explanation is best for the nurse to provide a client who asks the purpose of using the log-rolling technique for turning?

• A. Working together can decrease the risk of back injury.
• B. The technique is intended to maintain straight spinal alignment.
• C. Using two or three people increases client safety.
• D. Turning instead of pulling reduces the likelihood of skin damage.

Correct answer: B

Rationale: The correct answer is B: 'The technique is intended to maintain straight spinal alignment.' Log-rolling is a technique used to move a person as a single unit to maintain the alignment of the spinal column. This is crucial to prevent spinal cord injury, especially in clients with suspected spine fractures. Choice A is incorrect because log-rolling focuses on spinal alignment, not just decreasing back injury risks. Choice C is incorrect because the number of people involved is not the primary purpose of log-rolling, which is maintaining spinal alignment. Choice D is incorrect because while turning instead of pulling may help prevent skin damage, the primary goal of log-rolling is to protect the spine, not the skin.

4. The healthcare provider prescribes potassium chloride 25 mEq in 500 ml D5W to infuse over 6 hours. The available 20 ml vial of potassium chloride is labeled '10 mEq/5 ml.' How many ml of potassium chloride should the nurse add to the IV fluid?

• A. 12.5
• B. 5
• C. 10
• D. 20

Correct answer: B

Rationale: To prepare 25 mEq of potassium chloride for the infusion, the nurse should add 5 ml of the 10 mEq/5 ml solution. This concentration provides the required amount of potassium chloride without exceeding the needed volume. Choice A would result in 12.5 mEq, which exceeds the prescribed amount. Choices C and D are incorrect as they do not align with the correct calculation based on the vial concentration.

5. The nurse is assessing a client with left-sided heart failure who reports nocturia and dyspnea. The nurse identifies pulsus alternans and crackles in all lung fields. Which action is best to include in the client’s plan of care?

• A. Begin client education about positive inotropic medications.
• B. Place the client in Trendelenburg position.
• C. Prepare the client for an emergency cardiac catheterization.
• D. Monitor serum Troponin, CK, and CK-MB levels.

Correct answer: A

Rationale: In the scenario described, the client is exhibiting signs of left-sided heart failure, such as dyspnea, nocturia, pulsus alternans, and crackles in all lung fields. Positive inotropic medications are commonly used in the treatment of heart failure to improve cardiac contractility and output. Therefore, beginning client education about positive inotropic medications is the best action to include in the client's plan of care. Choice B is incorrect because placing the client in Trendelenburg position is not indicated in the management of left-sided heart failure. Choice C is incorrect as emergency cardiac catheterization is not typically the initial intervention for left-sided heart failure. Choice D is incorrect as monitoring serum Troponin, CK, and CK-MB levels is more pertinent to assessing for myocardial infarction rather than managing heart failure.

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