Nursing Elites

1. When assessing a client with early impairment of oxygen perfusion, such as a pulmonary embolus, the nurse should expect to find restlessness and which of the following symptoms?

• A. cool, clammy skin
• B. bradycardia
• C. tachycardia
• D. eupnea

Correct answer: C

Rationale: When a client has early impairment of oxygen perfusion, such as in a pulmonary embolus, the nurse should expect to find restlessness, diaphoresis, tachycardia, and cool skin. Tachycardia is a compensatory mechanism to increase oxygen delivery to tissues. Cool, clammy skin (choice A) is more indicative of impaired oxygen perfusion compared to warm, dry skin. Bradycardia (choice B) is less likely to occur in the early stages and is more common in severe cases. Eupnea (choice D) refers to normal respirations in rate and depth, which may not be altered in early impairment of oxygen perfusion.

2. For a client with suspected appendicitis, in which quadrant should the nurse expect to find abdominal tenderness?

• A. upper right
• B. upper left
• C. lower right
• D. lower left

Correct answer: C

Rationale: The correct answer is C: lower right. Abdominal tenderness in the lower-right quadrant is a classic sign of appendicitis. The appendix is located in the lower right abdomen, so inflammation of the appendix typically causes tenderness in this specific area. Choices A, B, and D are incorrect because tenderness in the upper right, upper left, and lower left quadrants, respectively, is not typical in appendicitis cases. Therefore, the nurse should focus on assessing the lower right quadrant for tenderness when suspecting appendicitis.

3. When teaching about preventable diseases, the importance of getting the following vaccines should be emphasized:

• A. human papillomavirus, genital herpes, measles.
• B. pneumonia, HIV, mumps.
• C. syphilis, gonorrhea, pneumonia.
• D. polio, pertussis, measles

Correct answer: D

Rationale: Vaccines are crucial in preventing communicable diseases. Smallpox has been eradicated globally, so its vaccine is no longer used. Polio, pertussis, and measles are diseases that are controlled by routine childhood immunization. While smallpox has been eradicated, these diseases still exist, making it essential for children to be vaccinated against them. Choices A, B, and C include diseases that are not prevented by vaccination or are not related to routine immunizations, making them incorrect choices.

4. A client with a history of peptic ulcer disease arrives in the emergency department complaining of weakness and states that he vomited 'a lot of dark coffee-looking stomach contents.' The client is cool and moist to the touch. BP 90/50, HR 110, RR 20, T 98. Of the following physician orders, which will the nurse perform first?

• A. Initiate oxygen at 2 liters/nasal cannula.
• B. Start an IV of NS at 150 ml/hr
• C. Insert NG tube to low suction
• D. Attach the client to the ECG monitor

Correct answer: A

Rationale: The correct answer is to initiate oxygen at 2 liters/nasal cannula. The client is presenting signs of shock with hypotension, tachycardia, and cool, moist skin, which indicate poor tissue perfusion. Oxygen should be administered first to improve tissue oxygenation. While all interventions are important, oxygenation takes priority in the ABCs of emergency care. Starting an IV of NS, inserting an NG tube, and attaching the client to the ECG monitor are necessary interventions but should follow the priority of oxygen administration in this scenario.

5. Which is an example of a sentinel event?

• A. The terminally ill client is referred to hospice and dies 3 months later.
• B. A client receives an unordered mammogram which reveals a small cyst.
• C. A client with a laceration to the knee requiring 4 sutures falls when getting up unassisted after being instructed to remain in bed.
• D. A client scheduled for knee replacement surgery had an above-the-knee amputation performed.

Correct answer: D

Rationale: Yes! A sentinel event is an unexpected occurrence causing death or serious injury. In this case, a client who was scheduled for knee replacement surgery but had an above-the-knee amputation performed instead represents a sentinel event as it resulted in serious harm that was not intended. The other choices do not meet the criteria for a sentinel event. Choice A describes a natural progression for a terminally ill client, choice B shows an incidental finding from a test, and choice C involves a preventable fall leading to an injury but not a sentinel event.

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