Nursing Elites

1. In monitoring tissue perfusion in a client following an above the knee amputation (AKA), which action should the nurse include in the plan of care?

• A. Evaluate closest proximal pulse.
• B. Note amount and color of wound drainage.
• C. Observe for swelling around the stump.
• D. Assess skin elasticity of the stump.

Correct answer: A

Rationale: After an amputation, monitoring the pulse closest to the stump is crucial in evaluating tissue perfusion and the overall health of the limb. Swelling and changes in perfusion can indicate complications such as blood clots or infection. Assessing the proximal pulse helps the nurse ensure adequate blood flow to the remaining limb, thereby preventing further complications. Choices B, C, and D are less directly related to monitoring tissue perfusion in this scenario and are more focused on wound healing and stump care.

2. A client with diabetes mellitus is scheduled for surgery, and their blood glucose level is 280 mg/dL. What is the nurse's priority action?

• A. Administer insulin as prescribed.
• B. Delay surgery until the blood glucose is below 180 mg/dL.
• C. Check the client’s hemoglobin A1C level.
• D. Administer IV fluids to flush excess glucose.

Correct answer: A

Rationale: The correct answer is A: Administer insulin as prescribed. In clients with diabetes, high blood glucose levels can increase the risk of infection and impair healing after surgery. Administering insulin as prescribed helps reduce blood glucose to a safer level before surgery, preventing complications. Choice B is incorrect because delaying surgery without addressing the high blood glucose level does not address the immediate issue. Choice C is incorrect as checking the client's hemoglobin A1C level is not the priority when dealing with acute high blood glucose levels before surgery. Choice D is incorrect as administering IV fluids may help with hydration but does not directly address the high blood glucose level that needs immediate attention.

3. A client with chronic obstructive pulmonary disease (COPD) is experiencing increased shortness of breath and fatigue. What is the nurse's first action?

• A. Administer a bronchodilator as prescribed.
• B. Check the client's oxygen saturation.
• C. Reposition the client to a high Fowler's position.
• D. Administer oxygen via nasal cannula.

Correct answer: B

Rationale: The correct first action for a client with COPD experiencing increased shortness of breath and fatigue is to check the client's oxygen saturation. This assessment helps the nurse evaluate the client's respiratory status promptly. Administering a bronchodilator (Choice A) may be necessary but should come after assessing the oxygen saturation. Repositioning the client to a high Fowler's position (Choice C) can help improve breathing but should not precede oxygen saturation assessment. Administering oxygen via nasal cannula (Choice D) may be needed based on the oxygen saturation results, but assessing it first is crucial.

4. A client receiving heparin therapy experiences a drop in platelet count. What is the nurse's priority action?

• A. Continue to monitor the platelet count.
• B. Discontinue the heparin infusion.
• C. Administer platelet transfusion.
• D. Notify the healthcare provider immediately.

Correct answer: D

Rationale: The correct answer is D: Notify the healthcare provider immediately. A drop in platelet count during heparin therapy may indicate heparin-induced thrombocytopenia (HIT), a serious condition that increases the risk of clot formation. Immediate discontinuation of heparin is necessary to prevent further complications. Administering platelet transfusion without addressing the underlying cause can be harmful. Continuing to monitor the platelet count without taking immediate action can lead to delayed intervention. Notifying the healthcare provider promptly allows for assessment and initiation of alternative anticoagulation therapy to manage the client's condition effectively.

5. A client with acute pancreatitis is experiencing severe abdominal pain. Which intervention should the nurse implement to help manage the client's pain?

• A. Encourage deep breathing exercises
• B. Place the client in a side-lying position with knees bent
• C. Administer oral analgesics as prescribed
• D. Encourage the client to take small sips of water

Correct answer: B

Rationale: The correct intervention to help manage the client's pain in acute pancreatitis is to place the client in a side-lying position with knees bent. This position can alleviate abdominal pain by reducing pressure on the pancreas and improving comfort. Encouraging deep breathing exercises (Choice A) is beneficial for other conditions but may not directly help alleviate abdominal pain in pancreatitis. Administering oral analgesics (Choice C) may be necessary but is not the initial priority for managing pain in acute pancreatitis. Encouraging the client to take small sips of water (Choice D) is important for hydration but is not directly related to pain management in this context.

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