Nursing Elites

1. The nurse enters a client's room to administer scheduled daily medications and observes the client leaning forward and using pursed lip breathing. Which action is most important for the nurse to implement first?

• A. Evaluate the oxygen saturation.
• B. Administer a bronchodilator.
• C. Assist the client to sit upright.
• D. Encourage slow, deep breathing.

Correct answer: A

Rationale: In this scenario, the nurse should first evaluate the oxygen saturation. This action is crucial as it provides immediate information on the client's respiratory status. Assessing the oxygen saturation can help determine the adequacy of oxygenation and guide further interventions. Administering a bronchodilator (Choice B) may be necessary based on assessment findings, but it should not be the first action without knowing the oxygen saturation level. While assisting the client to sit upright (Choice C) is generally beneficial for respiratory function, in this case, assessing oxygen saturation takes precedence. Encouraging slow, deep breathing (Choice D) can be helpful, but it is secondary to evaluating the oxygen saturation in this situation.

2. In assessing a client 48 hours following a fracture, the nurse observes ecchymosis at the fracture site and recognizes that hematoma formation at the bone fragment site has occurred. What action should the nurse implement?

• A. Document the extent of the bruising in the medical record.
• B. Apply a cold compress to the area.
• C. Elevate the affected limb.
• D. Notify the healthcare provider.

Correct answer: A

Rationale: After observing ecchymosis at the fracture site, indicating hematoma formation, the nurse's priority is to document the extent of the bruising in the medical record. This documentation helps track the client's condition, aids in treatment planning, and serves as a baseline for monitoring changes. Applying a cold compress (choice B) may be contraindicated due to the risk of vasoconstriction and potential tissue damage. Elevating the affected limb (choice C) can be beneficial for reducing swelling in some cases, but documenting the bruising is the immediate concern. Notifying the healthcare provider (choice D) is not necessary at this stage unless there are other concerning symptoms or complications beyond the hematoma formation.

3. The nurse is assessing a primigravida at 39-weeks gestation during a weekly prenatal visit. Which finding is most important for the nurse to report to the healthcare provider?

• A. Fetal heart rate of 200 beats/minute.
• B. Mild ankle edema.
• C. Complaints of back pain.
• D. Decreased fetal movements.

Correct answer: A

Rationale: A fetal heart rate of 200 beats per minute is significantly elevated and requires immediate medical attention. This finding could indicate fetal distress, tachycardia, or other serious issues that need prompt evaluation. Mild ankle edema, complaints of back pain, and decreased fetal movements are common in pregnancy but are not as urgent or concerning as a high fetal heart rate.

4. The nurse is planning care for a client admitted with a diagnosis of pheochromocytoma. Which intervention has the highest priority for inclusion in this client's plan of care?

• A. Record urine output every hour
• B. Monitor blood pressure frequently
• C. Evaluate neurological status
• D. Maintain seizure precautions

Correct answer: B

Rationale: Monitoring blood pressure frequently is the highest priority intervention for a client diagnosed with pheochromocytoma. This rare tumor can lead to life-threatening hypertension due to catecholamine secretion. Evaluating neurological status and maintaining seizure precautions are important but are not the highest priority in this case. Recording urine output, though essential for overall assessment, is not the priority compared to monitoring blood pressure in a client with pheochromocytoma.

5. A client with type 1 diabetes is admitted with diabetic ketoacidosis (DKA). Which laboratory value requires immediate intervention?

• A. Serum glucose of 300 mg/dl
• B. Serum potassium of 5.5 mEq/L
• C. Serum bicarbonate of 18 mEq/L
• D. Serum sodium of 135 mEq/L

Correct answer: C

Rationale: A serum bicarbonate level of 18 mEq/L requires immediate intervention in a client with diabetic ketoacidosis (DKA). A low serum bicarbonate level indicates metabolic acidosis, which can be life-threatening. This condition needs urgent correction to restore acid-base balance. Serum glucose of 300 mg/dl, serum potassium of 5.5 mEq/L, and serum sodium of 135 mEq/L are abnormal values, but they do not pose an immediate threat to the client's life compared to the metabolic acidosis indicated by the low serum bicarbonate level.

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