Nursing Elites

1. A nurse in an emergency room is caring for a client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?

• A. Insert an indwelling urinary catheter.
• B. Inspect the mouth for signs of inhalation injuries.
• C. Administer intravenous pain medication.
• D. Draw blood for a complete blood cell (CBC) count.

Correct answer: B

Rationale: When caring for a client with burns, especially burns to the face and chest, the priority action for the nurse is to inspect the mouth for signs of inhalation injuries. Inhalation injuries can be life-threatening and may not be immediately apparent. Identifying these injuries early allows for prompt intervention and can significantly impact the client's outcomes. While other actions such as pain management and blood tests are important, assessing for inhalation injuries takes precedence due to its critical nature.

2. A client who experienced a femur fracture 8 hr ago now reports sudden onset dyspnea and severe chest pain. Which of the following actions should the nurse take first?

• A. Provide high-flow oxygen.
• B. Check the client for a positive Chvostek's sign.
• C. Administer an IV vasopressor medication.
• D. Monitor the client for headache.

Correct answer: A

Rationale: In this situation, the priority action is to provide high-flow oxygen to the client. Sudden onset dyspnea and severe chest pain can be indicative of a pulmonary embolism, which is a life-threatening emergency. Oxygen therapy helps improve oxygenation and stabilizes the client's condition. Checking for Chvostek's sign, administering IV vasopressors, or monitoring for a headache are not the immediate priorities in this critical situation.

3. A healthcare professional is assessing a client who has a new onset of confusion. Which laboratory value should the professional check first?

• A. Blood glucose level
• B. Serum sodium level
• C. Serum calcium level
• D. Blood urea nitrogen (BUN)

Correct answer: A

Rationale: In a client presenting with a new onset of confusion, checking the blood glucose level first is crucial as hypoglycemia can cause confusion and is easily correctable. Addressing hypoglycemia promptly is essential to prevent further complications.

4. In an emergency department, a healthcare provider is preparing to care for a client with multiple system trauma following a motor vehicle crash. What should be the priority focus of care?

• A. Airway protection
• B. Decreasing intracranial pressure
• C. Stabilizing cardiac arrhythmias
• D. Preventing musculoskeletal disability

Correct answer: A

Rationale: In a client with multiple system trauma, airway protection is the priority focus of care. Ensuring a patent airway is crucial for oxygenation and ventilation, which are essential for maintaining vital functions. Without a clear airway, the client's oxygenation and ventilation could be compromised, leading to severe consequences. While decreasing intracranial pressure, stabilizing cardiac arrhythmias, and preventing musculoskeletal disability are important aspects of care, ensuring airway protection takes precedence in this emergency situation.

5. A client who received benzocaine spray before a recent bronchoscopy presents with continuous cyanosis despite oxygen therapy. What action should the nurse take next?

• A. Administer albuterol treatment.
• B. Notify Rapid Response Team.
• C. Assess the client's peripheral pulses.
• D. Obtain blood and sputum cultures.

Correct answer: B

Rationale: Cyanosis unresponsive to oxygen therapy suggests methemoglobinemia, an adverse effect of benzocaine spray. Methemoglobinemia can lead to death if not managed promptly. The nurse should notify the Rapid Response Team to provide immediate advanced care. Administering albuterol would not address the underlying cause of cyanosis. Assessing peripheral pulses and obtaining cultures are not the priority as they do not directly address the urgent need to manage methemoglobinemia.

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