Nursing Elites

1. A nurse at an outpatient clinic is returning phone calls that have been made to the clinic. Which of the following calls should have the highest priority for medical intervention?

• A. A home health patient reports, "I am starting to have a breakdown of my heels."?
• B. A patient that received an upper extremity cast yesterday reports, "I can't feel my fingers in my right hand today."?
• C. A young female reports, 'I think I sprained my ankle about 2 weeks ago.'
• D. A middle-aged patient reports, 'My knee is still hurting from the TKR.'

Correct answer: B

Rationale: The correct answer is the patient who received an upper extremity cast yesterday and reports not being able to feel their fingers in the right hand. This situation indicates a potential neurovascular issue that requires immediate attention to prevent complications. The other options are of lesser priority: A - Breakdown of the heels, while concerning, is not an acute issue that necessitates immediate intervention. C - An ankle sprain that occurred two weeks ago is now subacute and unlikely to be an urgent medical concern. D - Pain in the knee following a total knee replacement (TKR) is common in the early postoperative period and is not unexpected.

2. A nurse gave medications to the wrong client. She stated the client responded to the name called. What is the nurse's appropriate documentation?

• A. Note in medication records the drug given
• B. The client was not hurt, no need for documentation
• C. Note the client's orientation
• D. Completely fill out an incident report

Correct answer: D

Rationale: In the case where medications are given to the wrong client, the appropriate documentation by the nurse should involve completely filling out an incident report. This report is essential for tracking errors, implementing corrective measures, and ensuring patient safety. Choice A is incorrect because solely noting the drug given does not address the severity of the error. Choice B is incorrect because even if the client was not hurt, documentation is crucial for quality improvement and risk prevention. Choice C is incorrect as noting the client's orientation does not adequately address the medication error and its implications.

3. A patient has experienced a severe third-degree burn to the trunk in the last 36 hours. Which phase of burn management is the patient in?

• A. Shock phase
• B. Emergent phase
• C. Healing phase
• D. Wound proliferation phase

Correct answer: A

Rationale: The correct answer is A: Shock phase. The shock phase occurs within the first 24-48 hours of burn management. During this phase, the focus is on stabilization, fluid resuscitation, and monitoring for potential complications. Choice B, the Emergent phase, is incorrect as it refers to the initial phase of burn care immediately after the injury. Choice C, the Healing phase, occurs later in the treatment process when the wound starts to repair itself. Choice D, the Wound proliferation phase, is not a recognized phase in burn management.

4. Following a thyroidectomy, a client is complaining of shortness of breath (SOB) and neck pressure. Which nursing action is the best response?

• A. Stay with the client, remove the dressing, and elevate the head of bed.
• B. Call a code, open the trach set, and position the client supine.
• C. Have the client say "EEE"? to check for laryngeal integrity.
• D. Immediately go to the nurse's station and call the physician

Correct answer: A

Rationale: Correct! The client is displaying signs of respiratory distress after a thyroidectomy. By staying with the client, removing the dressing around the neck, and elevating the head of the bed, the nurse can assess the airway and breathing status more effectively. This immediate action can help alleviate any potential airway obstruction. Choice B is incorrect because calling a code and opening the trach set without initial assessment and basic interventions may delay necessary actions. Choice C is incorrect as having the client say "EEE"? is not as immediate or effective in addressing the respiratory distress. Choice D is incorrect as leaving the client alone and calling the physician without providing immediate assistance can be detrimental in a situation of potential airway compromise.

5. When teaching a client about anti-retroviral therapy for human immunodeficiency virus (HIV), the PN should emphasize:

• A. When started, therapy must not be interrupted to prevent viral resistance.
• B. When started, therapy must not be interrupted to prevent opportunistic infection.
• C. Therapy should not be interrupted for one day each month to prevent toxicity.
• D. Therapy should not be interrupted for one week every three months to prevent toxicity.

Correct answer: A

Rationale: When teaching a client about anti-retroviral therapy for HIV, it is crucial to emphasize that therapy must not be interrupted to prevent viral resistance. HIV mutates rapidly, and any interruption can lead to the emergence of resistant strains, compromising treatment effectiveness. Choice B is incorrect because keeping the virus in check with anti-retrovirals helps the client's immune system fight off opportunistic infections. Choices C and D are incorrect because therapy should not be interrupted for any reason. If toxicity occurs, the healthcare provider may adjust the treatment regimen by prescribing alternative anti-retroviral drugs.

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