Nursing Elites

1. In the Emergency Department, a female client discloses that she was raped last night. Which question is most important for the nurse to ask?

• A. Does she know the person who raped her?
• B. Has she taken a bath since the rape occurred?
• C. Is the place where she lives a safe place?
• D. Did she report the rape to the police department?

Correct answer: A

Rationale: The most important question for the nurse to ask in this situation is whether the client knows the person who raped her. This question is crucial for assessing additional safety concerns, providing appropriate support, and determining the need for forensic evidence collection. Choices B, C, and D are not as critical in the immediate assessment and response to a rape victim. Asking about bathing, the safety of her home, or reporting to the police may be important but are secondary to identifying the perpetrator for safety and legal reasons.

2. After receiving a report on an inpatient acute care unit, which client should the nurse assess first?

• A. The client with bowel obstruction due to a volvulus who is experiencing abdominal rigidity
• B. The client who had surgery yesterday and is experiencing a paralytic ileus with absent bowel sounds
• C. The client with an obstruction of the large intestine who is experiencing abdominal distention
• D. The client with a small bowel obstruction who has a nasogastric tube that is draining greenish fluid

Correct answer: A

Rationale: The correct answer is A. Abdominal rigidity in a client with bowel obstruction due to a volvulus indicates possible complications and requires immediate assessment. Choice B is incorrect because although a paralytic ileus with absent bowel sounds is concerning, abdominal rigidity in a client with a volvulus takes priority. Choice C is incorrect as abdominal distention, though indicative of an obstruction, is not as urgent as the sign of abdominal rigidity. Choice D is incorrect as the drainage of greenish fluid from a nasogastric tube in a client with a small bowel obstruction, while concerning, does not present as immediate a threat as the abdominal rigidity in a client with a volvulus.

3. After receiving report, which client should the nurse assess last?

• A. An older client with dark red drainage on a postoperative dressing, but no drainage in the Hemovac
• B. An adult client with no postoperative drainage in the Jackson-Pratt drain with the bulb compressed
• C. An older client with a distended abdomen and no drainage from the nasogastric tube
• D. An adult client with rectal tube draining clear pale red liquid drainage

Correct answer: D

Rationale: The correct answer is D because the client with rectal tube drainage of clear pale red liquid is likely to be the least urgent since this is a normal post-operative finding. Clear pale red liquid drainage from a rectal tube is typically not a cause for immediate concern. Choices A, B, and C present clients with concerning signs that may require more immediate assessment and intervention. A client with dark red drainage on a postoperative dressing may indicate active bleeding, a client with a compressed Jackson-Pratt drain bulb may have inadequate drainage resulting in complications, and a client with a distended abdomen and no drainage from the nasogastric tube may be experiencing gastrointestinal issues that need prompt evaluation.

4. A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant. While providing care, the nurse finds the radiation implant in the bed. What action should the nurse take?

• A. Call the radiology department
• B. Reinsert the implant into the vagina
• C. Apply double gloves to retrieve the implant for disposal
• D. Place the implant in a lead container using long-handled forceps

Correct answer: D

Rationale: The correct action for the nurse to take when finding a radiation implant in the bed is to place the implant in a lead container using long-handled forceps. This action is crucial to minimize radiation exposure to both the patient and healthcare providers and ensure the safe disposal of the radioactive material. Calling the radiology department (choice A) may lead to unnecessary delays in addressing the immediate safety concern. Reinserting the implant into the vagina (choice B) is contraindicated and can cause harm. Applying double gloves to retrieve the implant for disposal (choice C) is not adequate for ensuring proper containment and handling of the radioactive implant, which requires specialized equipment like a lead container and long-handled forceps.

5. A client complains of paresthesia in the fingers and toes and experiences hand spasms when the blood pressure cuff is inflated. Which serum laboratory finding should the nurse expect to find when assessing the client?

• A. Elevated serum calcium
• B. Low serum magnesium
• C. Low serum calcium
• D. Elevated serum potassium

Correct answer: C

Rationale: The correct answer is C: Low serum calcium. Hand spasms and paresthesia are indicative of potential hypocalcemia, which is characterized by low serum calcium levels. Elevated serum calcium (Choice A) is not consistent with the symptoms described. Low serum magnesium (Choice B) and elevated serum potassium (Choice D) are not typically associated with hand spasms and paresthesia.

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