Nursing Elites

1. Which of these findings should the nurse report immediately after a client has a liver biopsy?

• A. Temperature of 99.5 degrees F (37.5 degrees C)
• B. Blood pressure of 108/70
• C. Pulse oximetry reading of 96%
• D. Severe abdominal pain

Correct answer: D

Rationale: The correct answer is D, severe abdominal pain. After a liver biopsy, severe abdominal pain is a critical finding that requires immediate reporting as it may indicate internal bleeding or damage to the liver. The other vital signs provided in choices A, B, and C are within normal limits and may not be directly related to complications post liver biopsy. Therefore, the priority is to address the severe abdominal pain promptly to prevent any further complications.

2. The nurse identifies an electrolyte imbalance, a weight gain of 4.4 lbs in 24 hours, and an elevated central venous pressure for a client with full-thickness burns. Which intervention should the nurse implement?

• A. Administer diuretics
• B. Review urine output
• C. Auscultate for irregular heart rate
• D. Increase oral fluid intake

Correct answer: C

Rationale: An elevated CVP and sudden weight gain indicate fluid overload, which can strain the heart. Auscultating for an irregular heart rate is crucial as electrolyte imbalances and fluid shifts after burns can lead to cardiac complications. Monitoring the heart rate is a priority to detect any cardiac distress early. While reviewing urine output and administering diuretics are important interventions, they should come after ensuring the client's cardiac status is stable. Increasing oral fluid intake may exacerbate the fluid overload, making it an inappropriate intervention in this scenario.

3. While assessing an older client's fall risk, the client reports living at home alone and never falling. Which action should the nurse take?

• A. Suggest moving to an assisted living facility
• B. Continue to obtain client data needed to complete the fall risk survey
• C. Reduce the frequency of fall risk assessments for this client
• D. Confirm that the client is safe living alone

Correct answer: B

Rationale: The correct action for the nurse to take is to continue obtaining client data to complete the fall risk survey. Even though the client reports never falling, it is essential to assess all fall risk factors comprehensively. Fall risk surveys provide valuable information on mobility, vision, medications, and other factors that can impact safety. Option A is incorrect because suggesting moving to an assisted living facility is premature without completing the fall risk assessment. Option C is incorrect as reducing the frequency of fall risk assessments could overlook potential risk factors. Option D is incorrect as the client's statement alone is not enough to confirm their safety living alone; a thorough assessment is necessary.

4. A client presents with three positive responses to the CAGE questionnaire. What interpretation should the nurse provide?

• A. CAGE is a tool for general substance abuse screening.
• B. Two positive responses suggest alcohol dependence.
• C. One positive response does not indicate alcohol addiction.
• D. All four responses must be positive to suggest alcohol dependence.

Correct answer: B

Rationale: Two positive responses on the CAGE questionnaire strongly suggest alcohol dependence. Choice A is incorrect as the CAGE questionnaire specifically targets alcohol abuse. Choice C is incorrect because one positive response is not enough to indicate alcohol addiction. Choice D is incorrect because alcohol dependence can be suggested with two positive responses, not all four.

5. An adult male is brought to the ER after a motorcycle accident with periorbital bruising and bloody drainage from both ears. Which finding requires immediate attention?

• A. Rebound abdominal tenderness.
• B. Diminished breath sounds bilaterally.
• C. Rib pain with deep inspiration.
• D. Projectile vomiting.

Correct answer: D

Rationale: In this scenario, the patient's periorbital bruising and bloody drainage from both ears suggest a severe head injury. Projectile vomiting is a red flag symptom that may indicate increased intracranial pressure, which requires immediate attention to prevent further neurological deterioration. Rebound abdominal tenderness (choice A) typically indicates peritonitis and is not directly related to the primary head injury. Diminished breath sounds bilaterally (choice B) suggest a pneumothorax or hemothorax, which are important but not as immediately life-threatening in this context. Rib pain with deep inspiration (choice C) is concerning for rib fractures or pulmonary contusion, which are also important but do not take precedence over addressing the potential increased intracranial pressure.

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