Nursing Elites

1. When assessing a client several hours after surgery, the nurse observes that the client grimaces and guards the incision while moving in bed. The client is diaphoretic, has a radial pulse rate of 110 beats/min, and a respiratory rate of 35 breaths/min. What assessment should the nurse perform first?

• A. Apical heart rate
• B. IV site and fluids
• C. Pain scale
• D. Temperature

Correct answer: C

Rationale: The client’s grimacing and guarding suggest pain; assessing the pain scale is crucial for addressing the discomfort. Pain management is a priority to ensure the client's well-being and comfort. Checking the apical heart rate, IV site and fluids, or temperature can be important but addressing the client's pain takes precedence in this scenario. The elevated pulse rate and respiratory rate could be indicative of pain, making the pain scale assessment essential to guide appropriate interventions.

2. The healthcare provider prescribes a fluid challenge of 0.9% sodium chloride 1,000 ml to be infused over 4 hours. The IV administration set delivers 10gtt/ml. How many gtt/minute should the nurse regulate the infusion? (Enter a numeric value only. If rounding is required, round to the nearest whole number.)

• A. 42
• B.
• C.
• D.

Correct answer: A

Rationale: To calculate the rate: (1000 ml / 4 hours) = 250 ml/hour; (250 ml/hour) / (60 minutes/hour) = 4.17 ml/minute; (4.17 ml/minute) * (10 gtt/ml) = 41.7 gtt/minute, rounded to 42 gtt/minute. Therefore, the nurse should regulate the infusion at 42 gtt/minute to deliver the prescribed fluid challenge accurately. The other choices are incorrect as they do not reflect the correct calculation based on the given information.

3. A client morning assessment includes bounding peripheral pulses, weight gain of 2 pounds, pitting ankle edema, and moist crackles bilaterally. Which intervention is most important for the nurse to include in this client’s plan of care?

• A. Restrict daily fluid intake to 1500 ml
• B. Weight the client every morning
• C. Maintain accurate intake and output
• D. Administer prescribed diuretic

Correct answer: D

Rationale: Administering a prescribed diuretic is the most important intervention in this scenario as the client is presenting signs of fluid overload and heart failure. Diuretics help reduce fluid retention in the body, alleviating symptoms like edema and crackles. Restricting fluid intake may be necessary in some cases, but in this acute situation, addressing the immediate fluid overload with a diuretic takes precedence. Weighing the client daily and maintaining accurate intake and output are important aspects of monitoring, but they do not directly address the urgent need to manage fluid overload.

4. A client with type 2 diabetes mellitus is admitted for antibiotic treatment of a leg ulcer. Which signs and symptoms, indicative of hyperosmolar hyperglycemic nonketotic syndrome (HHNS), should the nurse report to the healthcare provider? (Select all that apply.)

• A. Increased heart rate
• B. Visual disturbances
• C. Presence of uremic frost
• D. Decreased mentation

Correct answer: A

Rationale: The correct signs and symptoms indicative of hyperosmolar hyperglycemic nonketotic syndrome (HHNS) include increased heart rate, visual disturbances, and decreased mentation. These symptoms are often associated with HHNS due to the high blood glucose levels. Uremic frost, a sign of advanced kidney disease, is not typically associated with HHNS. Therefore, choices B and D are incorrect. However, choice C, 'Presence of uremic frost,' is incorrect as it is not typically associated with HHNS.

5. A client with diabetic peripheral neuropathy has been taking pregabalin for 4 days. Which finding indicates to the nurse that the medication is effective?

• A. Granulating tissue in foot ulcer
• B. Full volume of pedal pulse
• C. Reduced level of pain
• D. Improved visual activity

Correct answer: C

Rationale: The correct answer is C: 'Reduced level of pain.' Pregabalin is used to manage neuropathic pain, so a reduction in pain indicates the medication's effectiveness in this case. Granulating tissue in a foot ulcer and the full volume of a pedal pulse are not direct indicators of pregabalin's effectiveness in managing neuropathic pain. Improved visual activity is not related to the effects of pregabalin in diabetic peripheral neuropathy.

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