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 with Parkinson's disease is prescribed carbidopa-levodopa (Sinemet). What should the nurse include in the teaching about this medication?

• A. Take the medication without a high-protein meal.
• B. Expect the medication to take several weeks to reach full effectiveness.
• C. The medication may cause urine to turn light.
• D. You may experience a rapid heartbeat as a common side effect.

Correct answer: B

Rationale: Patients prescribed carbidopa-levodopa should be informed that it may take several weeks for the medication to reach its full therapeutic effectiveness in managing Parkinson's disease symptoms. This delayed onset of action is important for patients to be aware of to prevent premature discontinuation of the medication due to perceived lack of efficacy.

3. A client learns about pursed-lip breathing. Which statement by the client indicates teaching has been effective?

• A. I will breathe in quickly through my mouth and out through my nose.
• B. I will breathe in slowly through my nose and out through pursed lips.
• C. I will hold my breath for 10 seconds before exhaling.
• D. I will breathe in and out through pursed lips.

Correct answer: B

Rationale: The correct technique for pursed-lip breathing involves inhaling slowly through the nose and exhaling slowly through pursed lips. This technique helps improve expiration and reduce air trapping. Breathing in quickly, holding the breath, or breathing in and out through pursed lips does not align with the correct method of pursed-lip breathing.

4. A client is postoperative with shallow respirations at 9/min. Which acid-base imbalance should the nurse identify the client as being at risk for developing initially?

• A. Respiratory acidosis
• B. Respiratory alkalosis
• C. Metabolic acidosis
• D. Metabolic alkalosis

Correct answer: A

Rationale: The client's shallow respirations at 9/min indicate hypoventilation, leading to an accumulation of carbon dioxide in the blood, causing respiratory acidosis. In this scenario, the client is at risk for developing respiratory acidosis due to inadequate ventilation and subsequent CO2 retention.

5. A client with a mediastinal chest tube is being assessed by a nurse. Which symptoms require the nurse's immediate intervention? (SATA)

• A. Production of pink sputum
• B. Tracheal deviation
• C. Pain at insertion site
• D. Sudden onset of shortness of breath

Correct answer: B

Rationale: Immediate intervention is necessary when a client with a mediastinal chest tube exhibits tracheal deviation since it may indicate a tension pneumothorax. This condition requires prompt attention to prevent serious complications. While the production of pink sputum and pain at the insertion site should be monitored and reported, they do not typically require immediate intervention. Sudden onset of shortness of breath could indicate various issues related to the chest tube but is not as critical as tracheal deviation in this context.

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