Nursing Elites

1. The nurse is assessing a female client's blood pressure because she reported feeling dizzy. The blood pressure cuff is inflated to 140 mm Hg and as soon as the cuff is deflated a Korotkoff sound is heard. Which intervention should the nurse implement next?

• A. Wait 1 minute and palpate the systolic pressure before auscultating again.
• B. Increase the inflation pressure by 20 mm Hg and measure again.
• C. Switch to a larger cuff and repeat the measurement.
• D. Document the finding as normal.

Correct answer: A

Rationale: If a Korotkoff sound is heard immediately upon deflation, it may indicate an inaccurate reading. Waiting and palpating the systolic pressure can help confirm the accuracy of the measurement. Choice A is the correct intervention because it allows the nurse to ensure the accuracy of the blood pressure reading. Choice B is incorrect as increasing the inflation pressure is not necessary in this situation. Choice C is also incorrect as switching to a larger cuff is not warranted based on the information provided. Choice D is incorrect because documenting the finding as normal without further verification could lead to inaccurate information.

2. A client presents to the labor and delivery unit, screaming 'THE BABY IS COMING.' Which action should the nurse implement first?

• A. Observe the perineum
• B. Prepare the delivery room
• C. Call the obstetrician
• D. Administer pain relief

Correct answer: A

Rationale: Observing the perineum is the priority action for the nurse in this situation. It allows the nurse to assess the stage of labor, determine the urgency of the situation, and provide immediate assistance if the baby is indeed about to be delivered. Preparing the delivery room and calling the obstetrician can follow once the nurse has assessed the situation. Administering pain relief may not be the immediate priority when the baby is coming.

3. The nurse is caring for a client with diabetic ketoacidosis (DKA). Which intervention is most important?

• A. Administer insulin as prescribed.
• B. Monitor the client's urine output.
• C. Assess the client's level of consciousness.
• D. Obtain an arterial blood gas (ABG) sample.

Correct answer: A

Rationale: Administering insulin is the most crucial intervention in managing diabetic ketoacidosis. Insulin helps reduce blood glucose levels and correct metabolic acidosis, which are the primary issues in DKA. Monitoring urine output (Choice B) is important but not as critical as administering insulin. Assessing the client's level of consciousness (Choice C) is essential but does not directly address the underlying cause of DKA. Obtaining an arterial blood gas sample (Choice D) can provide valuable information but is not as urgent as administering insulin to address the immediate metabolic imbalance.

4. Following a gunshot wound to the abdomen, a young adult male had an emergency bowel resection and received multiple blood products while in the operating room. His current blood pressure is 78/52 mm Hg, he is being mechanically ventilated, and his oxygen saturation is 87%. His laboratory values include hemoglobin 7.0 g/dL, platelets 20,000/mm³, and white blood cells 1,500/mm³. Based on these assessment findings, which intervention should the nurse implement first?

• A. Transfuse packed red blood cells.
• B. Obtain blood and sputum cultures.
• C. Infuse 1000 ml of normal saline.
• D. Titrate oxygen to keep O2 saturation at 90%.

Correct answer: A

Rationale: The client is exhibiting signs of severe anemia and hypovolemic shock, indicated by low hemoglobin levels and hypotension. The first priority is to address the low hemoglobin by transfusing packed red blood cells to improve oxygen-carrying capacity and perfusion to vital organs. While obtaining blood and sputum cultures is important for identifying potential infections, infusing normal saline can help with volume expansion but does not address the primary issue of severe anemia. Titrating oxygen to maintain an oxygen saturation of 90% is crucial but should follow the administration of packed red blood cells to optimize oxygen delivery.

5. An 80-year-old male client with multiple chronic health problems becomes disoriented, agitated, and combative 24 hours after being admitted to the hospital. What nursing intervention is most important to include in this client's plan of care?

• A. Request a psychiatric consultation for the client.
• B. Reorient the client frequently to time, place, and person.
• C. Administer prescribed antipsychotic medications to reduce agitation.
• D. Obtain an order for a sitter to stay with the client.

Correct answer: B

Rationale: Reorienting the client frequently is the most important nursing intervention in this scenario. It helps reduce confusion and agitation, which are common symptoms of acute delirium in hospitalized elderly clients. Requesting a psychiatric consult (choice A) may be necessary if the reorientation does not improve the client's condition or if there are underlying psychiatric concerns, but reorientation should be attempted first. Administering antipsychotic medications (choice C) should not be the initial intervention as they can have adverse effects in elderly individuals. Obtaining a sitter (choice D) may provide support but does not directly address the client's disorientation and agitation.

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