Nursing Elites

1. Following an open reduction and internal fixation of a compound fracture of the leg, a male client complains of “a tingly sensation” in his left foot. The nurse determines the client’s left pedal pulses are diminished. Based on these findings, what is the client’s greatest risk?

• A. Reduce pulmonary ventilation and oxygenation related to fat embolism.
• B. Neurovascular and circulation compromise related to compartment syndrome.
• C. Wound infection and delayed healing due to fractured bone protrusion.
• D. Venous stasis and thrombophlebitis related to postoperative immobility.

Correct answer: B

Rationale: The correct answer is B. Compartment syndrome is a serious condition that can occur following trauma or surgery, leading to compromised neurovascular status in the affected limb. Symptoms include pain, paresthesia (tingling sensation), and diminished pulses. If left untreated, compartment syndrome can result in tissue damage and potential loss of limb function. Options A, C, and D are incorrect because they do not directly address the neurovascular compromise associated with compartment syndrome.

2. A female client on the mental health unit tells the nurse that her roommate is sitting on the bathroom floor with superficial cuts on her wrists. The nurse cleans and assesses the client’s wrists and asks what happened. She doesn’t respond. What should the nurse do next?

• A. Find supplies to put a dressing on the client’s wrists
• B. Take the client to a room for supervision by staff
• C. Call the healthcare provider to report the client’s behavior
• D. Go find a staff member to stay in the room with the client

Correct answer: B

Rationale: In this situation, the nurse's priority is to ensure the safety and supervision of the client. Moving the client to a room for direct supervision by staff is crucial to prevent further harm and provide immediate support. While cleaning and assessing the client's wrists are important, ensuring ongoing supervision is vital in this scenario. Calling the healthcare provider to report the behavior may be necessary but is not the immediate action required. Finding supplies to dress the client's wrists is important but not as urgent as ensuring constant supervision by staff.

3. A male client with hypertension, who received new antihypertensive prescriptions at his last visit, returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106, and he admits that he has not been taking the prescribed medication because the drugs make him 'feel bad.' In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition?

• A. Feed the client a snack
• B. Empty the urinary drainage bag
• C. Offer the client oral fluids
• D. Stroke secondary to hemorrhage

Correct answer: D

Rationale: Elevated blood pressure, if left uncontrolled, significantly increases the risk of stroke secondary to hemorrhage and other cardiovascular events. This condition can lead to serious complications due to the increased pressure on the blood vessels in the brain. Choices A, B, and C are unrelated to the potential pathophysiological consequences of uncontrolled hypertension and are not the primary concern in this scenario.

4. After 2 days of treatment for dehydration, a child continues to vomit and have diarrhea. Normal saline is infusing, and the child’s urine output is 50ml/hour. During morning assessment, the nurse determines that the child is lethargic and difficult to arouse. Which action should the nurse implement?

• A. Perform a finger stick glucose test
• B. Increase the IV fluid flow rate
• C. Review 24-hour intake and output
• D. Obtain arterial blood gases

Correct answer: A

Rationale: Lethargy and difficulty arousing may indicate hypoglycemia, which should be assessed before other actions. Performing a finger stick glucose test is crucial to evaluate the child's blood sugar levels and address hypoglycemia promptly. Increasing the IV fluid flow rate is not indicated without knowing the glucose status. Reviewing 24-hour intake and output is important but not the priority when lethargy and difficulty arousing are present. Obtaining arterial blood gases is not the primary assessment needed in this situation.

5. An older male client is admitted to the mental health unit with a sudden onset of global disorientation and is continuously conversing with his mother, who died 50 years ago. The nurse reviews the multiple prescriptions the client is currently taking and assesses his urine specimen, which is cloudy, dark yellow, and has a foul odor. These findings suggest that this client is experiencing which condition?

• A. Psychotic episode
• B. Dementia
• C. Delirium
• D. Depression

Correct answer: C

Rationale: The correct answer is C, delirium. The sudden onset of global disorientation along with cloudy, dark yellow urine with a foul odor are indicative of delirium. Delirium is an acute condition characterized by a fluctuating disturbance in awareness and cognition. In this case, the symptoms are suggestive of an underlying physiological cause, such as infection or medication side effects. Choice A, psychotic episode, is less likely as the symptoms are more in line with delirium than a primary psychotic disorder. Choice B, dementia, is a chronic and progressive condition, not typically presenting with sudden onset disorientation. Choice D, depression, does not align with the acute cognitive changes and urine abnormalities described in the scenario.

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