Nursing Elites

1. While taking vital signs, a critically ill male client grabs the nurse's hand and asks the nurse not to leave. What action is best for the nurse to take?

• A. Pull up a chair and sit beside the client's bed.
• B. Reassure the client that you will return shortly.
• C. Ask another nurse to stay with the client.
• D. Continue taking vital signs and then leave the room.

Correct answer: A

Rationale: The best action for the nurse to take in this situation is to pull up a chair and sit beside the client's bed. By doing so, the nurse can provide emotional support and comfort to the critically ill patient who is feeling vulnerable. Sitting with the client also shows empathy and a willingness to listen to the client's needs. Reassuring the client that the nurse will return shortly (Choice B) may not address the immediate need for emotional support. Asking another nurse to stay with the client (Choice C) may not establish the same level of connection and comfort as sitting with the client personally. Continuing to take vital signs and then leaving the room (Choice D) disregards the client's emotional needs in that moment.

2. When finding a client sitting on the floor, the nurse calls for help from the unlicensed assistive personnel (UAP). Which task should the nurse ask the UAP to do?

• A. Check for any abrasions or bruises.
• B. Help the client to stand.
• C. Get a blood pressure cuff.
• D. Report the fall to the nurse-manager.

Correct answer: C

Rationale: The correct task for the nurse to ask the unlicensed assistive personnel (UAP) to do in this situation is to "Get a blood pressure cuff." This is important because assessing the client's vital signs, including blood pressure, is crucial after a fall to ensure there are no underlying issues like hypotension. Choices A and B may be important tasks for the nurse to perform as part of the assessment and care of the client. However, in this scenario, the immediate concern should be to check the client's blood pressure. Choice D is not the most urgent task at this time, as assessing the client's condition takes precedence.

3. A client with chronic obstructive pulmonary disease (COPD) is admitted with an exacerbation. Which laboratory value is most concerning?

• A. Serum potassium of 6.5 mEq/L
• B. Serum bicarbonate of 18 mEq/L
• C. Serum glucose of 350 mg/dl
• D. Serum sodium of 135 mEq/L

Correct answer: A

Rationale: A serum potassium level of 6.5 mEq/L is concerning in a client with COPD exacerbation as it may lead to life-threatening arrhythmias, requiring immediate intervention. Hyperkalemia can cause cardiac arrhythmias, which pose a significant risk to the patient's life. Options B, C, and D are not typically associated with immediate life-threatening risks in the context of a COPD exacerbation.

4. A client is admitted with a possible myocardial infarction. Which laboratory test result is most indicative of a myocardial infarction?

• A. Serum creatine kinase (CK)
• B. Serum troponin
• C. Serum myoglobin
• D. C-reactive protein (CRP)

Correct answer: B

Rationale: Serum troponin is the most specific and sensitive indicator of myocardial infarction. Troponin levels rise within 3-4 hours after myocardial damage, peak at 10-24 hours, and remain elevated for up to 10-14 days. Creatine kinase (CK) and myoglobin can also be elevated in myocardial infarction, but troponin is more specific to cardiac muscle damage. C-reactive protein (CRP) is a marker of inflammation and is not specific for myocardial infarction.

5. The nurse notes that a client has been receiving hydromorphone (Dilaudid) every six hours for four days. What assessment is most important for the nurse to complete?

• A. Auscultate the client's bowel sounds
• B. Observe for edema around the ankles
• C. Measure the client's capillary glucose level
• D. Count the apical and radial pulses simultaneously

Correct answer: A

Rationale: The correct answer is to auscultate the client's bowel sounds. Hydromorphone is a potent opioid analgesic that can slow peristalsis and commonly cause constipation. By assessing the client's bowel sounds, the nurse can monitor for any signs of decreased bowel motility or potential constipation. Observing for edema (Choice B) is not directly related to hydromorphone administration. Measuring capillary glucose levels (Choice C) is not the priority in this situation. Counting the apical and radial pulses simultaneously (Choice D) is not specifically indicated in this scenario involving hydromorphone administration.

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