Nursing Elites

1. Which assessment is most important for the nurse to include in the daily plan of care for a client with a burned extremity?

• A. Distal pulse intensity
• B. Skin integrity
• C. Pain levels
• D. Range of motion

Correct answer: A

Rationale: The correct answer is A: Distal pulse intensity. Monitoring distal pulses is crucial to ensure that circulation to the extremity is not compromised. This assessment helps in detecting any signs of decreased circulation, which is vital in managing a burned extremity. While skin integrity (choice B), pain levels (choice C), and range of motion (choice D) are also important assessments, monitoring distal pulse intensity takes precedence as it directly reflects the perfusion status of the affected extremity in a burned client.

2. The nurse is caring for a client with a chest tube following a pneumothorax. Which assessment finding requires immediate intervention?

• A. Oxygen saturation of 94%
• B. Subcutaneous emphysema
• C. Crepitus around the insertion site
• D. Drainage of 50 ml per hour

Correct answer: B

Rationale: Subcutaneous emphysema is the correct answer as it is most concerning in a client with a chest tube following a pneumothorax. It may indicate a pneumothorax recurrence or air leak, requiring immediate intervention to prevent complications. Oxygen saturation of 94% is acceptable and does not require immediate intervention. Crepitus around the insertion site may be a normal finding after chest tube placement and does not necessarily indicate a complication. Drainage of 50 ml per hour is within the expected range for a chest tube and does not require immediate intervention.

3. A client with heart failure is receiving digoxin (Lanoxin) and furosemide (Lasix). Which assessment finding requires immediate intervention?

• A. Heart rate of 60 beats per minute
• B. Apical pulse of 58 beats per minute
• C. Presence of a new murmur
• D. Blood pressure of 100/60 mmHg

Correct answer: C

Rationale: The correct answer is C. The presence of a new murmur in a client with heart failure receiving digoxin and furosemide is concerning as it may indicate valvular problems or other complications that require immediate intervention. A heart rate of 60 beats per minute and an apical pulse of 58 beats per minute are within normal limits for a client with heart failure on these medications. A blood pressure of 100/60 mmHg, while slightly low, may be expected due to the diuretic effect of furosemide and may not require immediate intervention unless the client is symptomatic.

4. During the initial visit to a client with MS who is bed-bound and lifted by a hoist, which intervention is most important for the nurse to implement?

• A. Determine how the client is cared for when the caregiver is not present.
• B. Develop a client needs assessment and review it with the caregiver.
• C. Evaluate the caregiver's ability to care for the client's needs.
• D. Review with the caregiver the interventions provided each day.

Correct answer: A

Rationale: During the initial visit, the most crucial intervention for the nurse is to determine how the client is cared for when the caregiver is not present. This is essential to ensure the client's safety and well-being, especially during times when the caregiver is not available. Option B is not the most important as it focuses on assessment rather than immediate safety concerns. Option C, while important, is secondary to ensuring continuous care. Option D is less critical during the initial visit compared to ensuring care continuity in the caregiver's absence.

5. A client with a history of congestive heart failure is admitted with shortness of breath. Which nursing intervention should the nurse implement first?

• A. Elevate the head of the bed.
• B. Administer prescribed diuretic therapy.
• C. Monitor the client's oxygen saturation.
• D. Assess the client's level of consciousness.

Correct answer: A

Rationale: The correct answer is to elevate the head of the bed. Elevating the head of the bed is crucial in improving oxygenation in clients with congestive heart failure and shortness of breath by reducing venous return to the heart and decreasing fluid overload in the lungs. This intervention helps to alleviate the client's breathing difficulty. Administering diuretic therapy (Choice B) may be necessary but is not the initial priority. Monitoring oxygen saturation (Choice C) is important but should come after ensuring proper positioning. Assessing the client's level of consciousness (Choice D) is essential but is not the first intervention needed for a client experiencing respiratory distress.

Similar Questions