Nursing Elites

1. The nurse has just received a change-of-shift report. Which client should the nurse assess first?

• A. A client 2 hours post-lobectomy with 150cc drainage
• B. A client 2 days post-gastrectomy with scant drainage
• C. A client with pneumonia with an oral temperature of 102�F
• D. A client with a fractured hip in Buck's traction

Correct answer: A

Rationale: The nurse should assess the client 2 hours post-lobectomy with 150cc drainage first because postoperative assessments are crucial during the immediate postoperative period. This client may be at higher risk for complications, such as bleeding or infection, requiring immediate attention. Clients in choices B, C, and D are relatively stable and can be assessed after the immediate postoperative client has been evaluated.

2. A client is admitted to the floor with vomiting and diarrhea for three days. She is receiving IV fluids at 200cc/hr via pump. A priority action for the nurse would be:

• A. Obtaining Intake and Output.
• B. Frequent lung assessments.
• C. Vital signs every shift.
• D. Monitoring the IV site for infiltration.

Correct answer: D

Rationale: In this scenario, the correct priority action for the nurse would be monitoring the IV site for infiltration. The client is receiving IV fluids at a rapid rate, making it crucial to ensure that the IV site is intact and not causing any complications like infiltration, which can lead to tissue damage. While frequent lung assessments are important for detecting signs of fluid overload, in this case, ensuring the IV site's integrity takes precedence. Obtaining Intake and Output is relevant but not the priority over monitoring the IV site. Vital signs are essential, but given the situation, the immediate concern is the IV site's condition to prevent complications.

3. The client in the Emergency Department, who has suffered an ankle sprain, should be taught to:

• A. use cold applications to the sprain during the first 24-48 hours.
• B. expect disability to decrease within the first 24 hours of injury
• C. expect pain to decrease within 3 hours after injury.
• D. begin progressive passive and active range of motion exercises immediately.

Correct answer: A

Rationale: When a client suffers an ankle sprain, the nurse should teach them to use cold applications to the sprain during the first 24-48 hours. Cold applications are believed to produce vasoconstriction and reduce the development of edema. Expecting disability to decrease within the first 24 hours of injury (choice B) is incorrect as disability and pain are anticipated to increase during the first 2-3 hours after injury. Expecting pain to decrease within 3 hours after injury (choice C) is also incorrect as pain and swelling usually increase initially. Beginning progressive passive and active range of motion exercises immediately (choice D) is not recommended; these exercises are usually started 2-5 days after the injury, according to the physician's recommendation. Treatment for a sprain involves support, rest, and alternating cold and heat applications. X-ray pictures are often necessary to rule out any fractures.

4. Which of the following is not typically considered one of the main mechanisms of Type II Diabetes treatment?

• A. Medications
• B. Nutrition
• C. Increased activity
• D. Continuous Insulin

Correct answer: D

Rationale: Continuous Insulin is not typically considered one of the main mechanisms for treating Type II Diabetes. While medications, nutrition, and increased activity play crucial roles in managing Type II Diabetes, continuous insulin therapy is more common in Type I Diabetes or in specific cases of Type II Diabetes where other treatments are ineffective. Therefore, the correct answer is Continuous Insulin. Choices A, B, and C are mainstays in the treatment of Type II Diabetes, making them incorrect answers.

5. A nurse is assessing an 18-year-old female who has recently suffered a TBI. The nurse notes a slower pulse and impaired respiration. The nurse should report these findings immediately to the physician due to the possibility the patient is experiencing which of the following conditions?

• A. Increased intracranial pressure
• B. Increased function of cranial nerve X
• C. Sympathetic response to activity
• D. Meningitis

Correct answer: A

Rationale: The nurse should report the slower pulse and impaired respiration to the physician immediately as they are indicative of increased intracranial pressure (ICP) following a traumatic brain injury (TBI). These signs suggest that there may be a rise in pressure within the skull, which can be a life-threatening condition requiring urgent intervention. Options B and C are unlikely in this scenario as they do not correlate with the symptoms presented. Meningitis (Option D) typically presents with different signs and symptoms, such as fever, headache, and neck stiffness, which are not described in the patient's case.

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