Nursing Elites

1. The settings on a client's synchronized intermittent mandatory ventilation (SIMV) are respiratory rate 12 breaths/minute, tidal volume at 600 mL, FiO2 35%, and positive end-expiratory pressure (PEEP) 5 cm H2O. Which assessment finding necessitates immediate intervention by the nurse?

• A. Bilateral crackles in the lung bases.
• B. Low-pressure indicator alarm.
• C. Oxygen saturation of 91%.
• D. Respiratory rate of 18 breaths/minute.

Correct answer: B

Rationale: A low-pressure alarm may indicate a disconnection or leak in the system, which needs immediate intervention. Bilateral crackles in the lung bases may indicate fluid overload but do not require immediate intervention in this case. An oxygen saturation of 91% is concerning but not as urgent as a potential equipment issue. A respiratory rate of 18 breaths/minute is higher than the set rate but may not necessitate immediate intervention unless accompanied by other distress symptoms.

2. What should the nurse assess in an infant who has been diagnosed with hypertrophic pyloric stenosis?

• A. A history of diarrhea following each feeding
• B. Gastric pain evidenced by vigorous crying
• C. Poor appetite due to a poor sucking reflex
• D. An olive-shaped mass right of the midline

Correct answer: D

Rationale: The correct answer is D. In hypertrophic pyloric stenosis, a key assessment finding is an olive-shaped mass in the right upper quadrant of the abdomen, to the right of the midline. This mass is palpable and represents the hypertrophied pyloric muscle. Choices A, B, and C are incorrect because although they may be present in infants with feeding problems, the definitive assessment for hypertrophic pyloric stenosis is the presence of an olive-shaped mass on the right side of the abdomen, not a history of diarrhea, gastric pain, or poor appetite.

3. A client who took a camping vacation two weeks ago in a country with a tropical climate comes to the clinic describing vague symptoms and diarrhea for the past week. Which finding is most important for the nurse to report to the HCP?

• A. Weakness and fatigue
• B. Intestinal cramping
• C. Weight loss
• D. Jaundiced sclera

Correct answer: D

Rationale: The most important finding to report to the healthcare provider is a jaundiced sclera. Jaundice suggests liver involvement, which can be a sign of a serious underlying condition. Weakness and fatigue, intestinal cramping, and weight loss are important symptoms, but jaundice indicates a more urgent issue that needs immediate attention.

4. Before selecting which medication to administer, which action should the nurse implement if a postoperative client reports incisional pain and has two prescriptions for PRN analgesia?

• A. Compare the client’s pain scale rating with the prescribed dosing.
• B. Determine which prescription will have the quickest onset of action.
• C. Ask the client to choose which medication is needed for the pain.
• D. Document the client’s report of pain in the electronic medical record.

Correct answer: A

Rationale: When a postoperative client reports incisional pain and has two prescriptions for PRN analgesia, the nurse should first compare the client’s pain scale rating with the prescribed dosing. This action ensures that the client receives the appropriate medication based on their pain level. Determining the onset of action or asking the client to choose the medication does not guarantee that the right medication is administered according to the pain intensity. Documenting the pain report is important but should not be the first action when deciding which medication to administer.

5. Parents of a 5-year-old child diagnosed with cognitive impairment have come to the nurse to discuss different approaches to the ongoing care of their child. The nurse should suggest focusing on what activity?

• A. Acquiring job skills
• B. Making decisions
• C. Performing self-care activities
• D. Reading and doing simple math

Correct answer: C

Rationale: The correct answer is C: Performing self-care activities. For a 5-year-old child diagnosed with cognitive impairment, it is crucial to focus on teaching them basic self-care skills. This includes activities like dressing themselves, feeding, and personal hygiene. These skills are fundamental for their daily living and independence. Choices A, B, and D are not appropriate for a young child with cognitive impairment. Acquiring job skills is not developmentally suitable at this age, making decisions may be challenging due to cognitive limitations, and reading and doing simple math may be too advanced for their current cognitive abilities.

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