Nursing Elites

1. The emergency department charge nurse is reviewing the clients triaged in the last 30 minutes. The nurse is required to obtain a social service consult from which of the following clients?

• A. A 6-year-old who drank some diluted bleach.
• B. A 10-year-old who suffered burns in a house fire.
• C. A 12-year-old who fractured his arm in a fight at school.
• D. A 12-month-old without any oral intake for the last 12 hours.

Correct answer: A

Rationale: For children under 7 years, most states have laws that mandate reporting certain situations to social services or child protection, such as ingestions of toxic substances, fractures, suspected neglect, or abuse, and burns. In this scenario, the 6-year-old who drank diluted bleach falls under the category that requires a social service consult. The other choices involve injuries or conditions that may warrant medical attention but do not necessarily mandate a social service consult based on age-related legal requirements.

2. After a left heart catheterization (LHC), a client complains of severe foot pain on the side of the femoral stick. The nurse notes pulselessness, pallor, and a cold extremity. What should the nurse's next action be?

• A. Administer an anticoagulant.
• B. Warm the room and re-assess.
• C. Increase IV fluids.
• D. Notify the physician stat.

Correct answer: D

Rationale: The correct action for the nurse to take next is to notify the physician immediately (stat). The client's symptoms of foot pain, pulselessness, pallor, and cold extremity suggest a potential vascular complication, such as arterial occlusion. Prompt notification of the physician is crucial as this condition requires urgent intervention to restore blood flow and prevent tissue damage. Administering an anticoagulant (Choice A) without physician evaluation could be harmful as the underlying cause needs to be determined first. Warming the room and re-assessing (Choice B) may delay necessary treatment. Increasing IV fluids (Choice C) is unlikely to address the urgent vascular issue indicated by the symptoms described.

3. A client has chronic respiratory acidosis caused by end-stage chronic obstructive pulmonary disease (COPD). Oxygen is delivered at 1 L/min via nasal cannula. The nurse teaches the family that the reason for this is to avoid respiratory depression, based on which of the following explanations?

• A. COPD clients are stimulated to breathe by hypoxia.
• B. COPD clients depend on a low carbon dioxide level.
• C. COPD clients tend to retain hydrogen ions if they are given high doses of oxygen.
• D. COPD clients thrive on a high oxygen level.

Correct answer: A

Rationale: In clients with COPD and chronic respiratory acidosis, they are compensating for low oxygen and high carbon dioxide levels. Hypoxia acts as the main stimulus to breathe in individuals with chronic hypercapnia. When oxygen is administered, it can decrease the respiratory drive by eliminating the hypoxic drive and reducing the stimulus to breathe. Therefore, delivering oxygen at 1 L/min via nasal cannula helps prevent respiratory depression by maintaining the hypoxic drive to breathe. The other options are incorrect: COPD clients do not depend on a low carbon dioxide level as they are chronically hypercapnic, they do not retain hydrogen ions with high oxygen doses, and they do not thrive on a high oxygen level.

4. The nurse is caring for a client who is 28 weeks pregnant and complains of swollen hands and feet. Which symptom below would cause the greatest concern?

• A. Nasal congestion
• B. Hiccups
• C. Blood glucose of 150
• D. Muscle spasms

Correct answer: D

Rationale: The correct answer is muscle spasms because they can be indicative of a severe condition like preeclampsia, which is a serious complication during pregnancy characterized by high blood pressure and signs of damage to another organ system, most often the liver and kidneys. Nasal congestion and hiccups are common discomforts during pregnancy and do not pose a severe risk to the client or fetus. A blood glucose level of 150, while slightly elevated, may not be alarming in a pregnant individual and can be managed through dietary modifications or medication adjustments. Muscle spasms, especially in the context of pregnancy, should be taken seriously and thoroughly assessed to rule out any underlying serious conditions.

5. A client begins a regimen of chemotherapy. Her platelet count falls to 98,000. Which action is least likely to increase the risk of hemorrhage?

• A. Test all excreta for occult blood.
• B. Use a soft toothbrush or foam cleaner for oral hygiene.
• C. Implement reverse isolation.
• D. Avoid IM injections.

Correct answer: C

Rationale: The correct answer is to implement reverse isolation. Reverse isolation is a protective measure used to protect patients from infections, not to affect the risk of hemorrhage. Testing all excreta for occult blood (Choice A) is important to monitor for signs of internal bleeding. Using a soft toothbrush or foam cleaner for oral hygiene (Choice B) is recommended to prevent gum bleeding. Avoiding IM injections (Choice D) is crucial to reduce the risk of bleeding in a client with a low platelet count. Therefore, among the given options, implementing reverse isolation is the least likely to increase the risk of hemorrhage.

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