Nursing Elites

1. A nurse in an emergency department completes an assessment on an adolescent client with conduct disorder. The client threatened suicide to a teacher at school. Which of the following statements should the nurse include in the assessment?

• A. Tell me about your siblings
• B. Tell me what kind of music you like
• C. Tell me how often you drink alcohol
• D. Tell me about your school schedule

Correct answer: C

Rationale: Asking about alcohol intake is crucial in assessing the client's risk factors and behaviors, especially in the context of a suicide threat. Understanding alcohol consumption patterns can help the nurse evaluate potential substance abuse issues and their impact on the client's mental health. Choices A, B, and D are less pertinent to the immediate concern of assessing suicide risk and conduct disorder symptoms.

2. A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect?

• A. Peripheral edema.
• B. Cough with frothy sputum.
• C. Jugular vein distention.
• D. Dependent edema.

Correct answer: C

Rationale: The correct answer is C: Jugular vein distention. In left-sided heart failure, the left ventricle fails to efficiently pump blood to the body, causing increased pressure in the pulmonary circulation. This increased pressure can lead to symptoms like jugular vein distention, as blood backs up in the pulmonary circulation and causes congestion. Choices A, B, and D are incorrect: Peripheral edema is more commonly associated with right-sided heart failure, cough with frothy sputum is a sign of pulmonary edema which can occur in left-sided heart failure but is not as specific as jugular vein distention, and dependent edema is also more indicative of right-sided heart failure due to fluid retention and increased venous pressure in the systemic circulation.

3. When collecting a sputum specimen from a client with tuberculosis, what action should the nurse take?

• A. Obtain the specimen immediately upon the client waking up.
• B. Wait one day to collect the specimen if the client cannot provide sputum.
• C. Ask the client to provide 15 to 20 ml of sputum.
• D. Wear sterile gloves when collecting the specimen.

Correct answer: A

Rationale: The correct answer is to obtain the specimen immediately upon the client waking up. Collecting sputum early in the morning provides the best sample for tuberculosis testing. Option B is incorrect because waiting a day can decrease the accuracy of the specimen. Option C is incorrect as it does not specify the optimal timing for specimen collection. Option D is incorrect as sterile gloves should be worn for infection control but do not specifically relate to the timing of specimen collection.

4. A client has a stage 3 pressure injury. Which of the following interventions should the nurse include in the plan?

• A. Cleanse the wound with povidone-iodine solution daily.
• B. Irrigate the wound with hydrogen peroxide.
• C. Reposition the client every 4 hours.
• D. Apply a moisture barrier ointment.

Correct answer: D

Rationale: The correct intervention for a client with a stage 3 pressure injury is to apply a moisture barrier ointment. This helps protect the skin, maintain moisture balance, and promote healing. Choice A is incorrect because povidone-iodine solution can be too harsh for wound care. Choice B is incorrect as hydrogen peroxide can be cytotoxic to healing tissue. Choice C is important for preventing pressure injuries but is not a direct intervention for a stage 3 wound.

5. A nurse in an emergency department is assessing a newly admitted client who is experiencing drooling and hoarseness following a burn injury. Which of the following actions should the nurse take first?

• A. Obtain a baseline ECG
• B. Obtain a blood specimen for ABG analysis
• C. Insert an 18-gauge IV catheter
• D. Administer 100% humidified oxygen

Correct answer: D

Rationale: In a client experiencing drooling and hoarseness following a burn injury, the priority action for the nurse is to administer 100% humidified oxygen. This is crucial to maintain the airway and address respiratory distress, which takes precedence over obtaining an ECG, collecting blood for ABG analysis, or inserting an IV catheter. Providing oxygen therapy is essential in ensuring the client's oxygenation and respiratory function are optimized in this emergency situation.

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