Nursing Elites

1. On a day when the temperature is expected to drop below freezing during the night, the nurse is asked to determine which homeless adults are most in need of the limited spaces available in a shelter. It is most important for which person to be admitted at night?

• A. an adult who was hit by a car 3 weeks ago
• B. a young person with diabetes mellitus
• C. a middle-aged person who has hypertension
• D. an older person who is malnourished

Correct answer: D

Rationale: Malnourished individuals are at higher risk of severe complications from cold exposure due to their weakened immune system and decreased ability to regulate body temperature. This places them at a greater risk of hypothermia and other cold-related conditions, making them the most vulnerable group in need of shelter. Choice A is not the most critical as the injury is from 3 weeks ago and should have received appropriate medical care by now. Choice B, a young person with diabetes mellitus, while vulnerable, can manage their condition with proper medication and care. Choice C, a middle-aged person with hypertension, may need monitoring but is less susceptible to immediate harm from cold exposure compared to a malnourished individual.

2. During a follow-up home visit, the nurse observes that a client with chronic obstructive pulmonary disease (COPD) is using accessory muscles to breathe and has a pulse oximetry reading of 88%. What action should the nurse take first?

• A. Administer a prescribed bronchodilator
• B. Increase the oxygen flow rate
• C. Instruct the client to perform pursed-lip breathing
• D. Notify the healthcare provider immediately

Correct answer: C

Rationale: In this situation, the nurse should first instruct the client to perform pursed-lip breathing. Pursed-lip breathing helps improve oxygenation and decrease the work of breathing in clients with COPD. Administering a bronchodilator or increasing the oxygen flow rate may be necessary interventions but addressing the breathing technique through pursed-lip breathing is the initial action to optimize oxygenation. Notifying the healthcare provider immediately is not the first action indicated in this scenario; the nurse should intervene promptly to assist the client in improving breathing before escalating the situation.

3. While assessing a client receiving a blood transfusion, which finding requires immediate intervention?

• A. Temperature of 100.4°F (38°C).
• B. Blood pressure of 110/70 mm Hg.
• C. Heart rate of 90 beats per minute.
• D. Complaints of feeling cold.

Correct answer: C

Rationale: A heart rate of 90 beats per minute requires immediate intervention when assessing a client receiving a blood transfusion. This finding can indicate a potential transfusion reaction, such as a hemolytic reaction or fluid overload, which requires prompt evaluation and management to prevent serious complications. While a temperature of 100.4°F (38°C) may indicate a mild fever, it is not typically an immediate concern during a blood transfusion. A blood pressure of 110/70 mm Hg is within the normal range and does not necessitate immediate intervention. Complaints of feeling cold can be addressed but do not indicate an urgent need for intervention compared to the critical nature of a potential transfusion reaction indicated by an elevated heart rate.

4. A client who has been receiving chemotherapy for cancer has a platelet count of 20,000/mm3. Which intervention should the nurse include in the plan of care?

• A. Apply ice packs to bruised areas.
• B. Encourage frequent oral hygiene.
• C. Avoid invasive procedures.
• D. Place the client in a private room.

Correct answer: C

Rationale: The correct intervention for a client with a platelet count of 20,000/mm3 due to chemotherapy is to avoid invasive procedures. Chemotherapy can cause a decrease in platelet count, leading to an increased risk of bleeding. By avoiding invasive procedures, the nurse helps reduce the risk of bleeding complications. Applying ice packs to bruised areas (Choice A) may further increase the risk of bleeding due to the pressure and potential trauma to the skin. Encouraging frequent oral hygiene (Choice B) is important for overall health but does not directly address the risk of bleeding associated with a low platelet count. Placing the client in a private room (Choice D) is not directly related to managing the platelet count and risk of bleeding; it is more about privacy and infection control, which are important but not the priority in this scenario.

5. During a 2-week postoperative follow-up home visit, a female client who had gastric bypass surgery exhibits abdominal tenderness, shoulder pain, and describes feelings of malaise. Her vital signs are: T 101.8, BP 100/50, HR 104, and RR 18. Which action should the RN take?

• A. have the client transported via ambulance to the hospital
• B. recheck the client's vital signs in 30 minutes
• C. instruct the client to drive to the hospital for admission
• D. assess the client's current symptoms

Correct answer: A

Rationale: The client is presenting with signs of a potential postoperative complication, such as fever, low blood pressure, and tachycardia, which could indicate sepsis or another serious issue. These symptoms require immediate hospital evaluation and management. Option B of rechecking vital signs in 30 minutes could delay crucial intervention in a potentially life-threatening situation. Option C is unsafe as the client should not drive herself due to her condition. Option D is vague and does not address the urgency of the situation.

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