Nursing Elites

1. In the emergency department, a nurse is assessing a client involved in a motor vehicle crash. Findings include absent breath sounds in the left lower lobe with dyspnea, blood pressure 118/68 mm Hg, heart rate 124/min, respirations 38/min, temperature 38.6 C (101.4 F), and SaO2 92% on room air. What action should the nurse take first?

• A. Obtain a chest X-ray.
• B. Prepare for chest tube insertion.
• C. Administer oxygen via high-flow mask.
• D. Initiate IV access.

Correct answer: C

Rationale: In this scenario, the client is presenting with signs of respiratory distress, including absent breath sounds, dyspnea, and a low SaO2 level. The priority action should be to improve oxygenation by administering oxygen via a high-flow mask. This intervention aims to increase the oxygen supply to the client's lungs, helping to address the hypoxemia. Once oxygenation is optimized, further interventions, such as obtaining a chest X-ray, preparing for chest tube insertion, or initiating IV access, can be considered based on the client's condition and healthcare provider's orders.

2. When preparing to administer eye drops to a school-age child, what actions should a nurse take?

• A. 52341
• B. 53241
• C. 35241
• D. 14325

Correct answer: A

Rationale: The correct sequence for administering eye drops to a school-age child is as follows: 5. Place the child in a sitting position, 2. Ask the child to look upward, 3. Pull the lower eyelid downward, 4. Instill the drops of medication, and 1. Apply pressure to the lacrimal punctum. Placing the child in a sitting position helps with stability and ease of access. Asking the child to look upward helps expose the conjunctival sac. Pulling the lower eyelid downward creates a pouch for instilling the drops. Instilling the drops of medication directly into the pouch ensures proper administration, and applying pressure to the lacrimal punctum prevents systemic absorption and promotes local action of the medication.

3. A nurse manager is developing a protocol for an urgent care clinic that often cares for clients who do not speak the same language as clinical staff. Which of the following instructions should the nurse include?

• A. Use a professional interpreter service
• B. Nurse to interpret
• C. Provide translation services for a nominal fee to clients
• D. Evaluate the clients' understanding at regular intervals

Correct answer: B

Rationale: In situations where there is a language barrier between healthcare providers and patients, it is essential to ensure accurate communication. Using professional interpreter services is the most appropriate choice to ensure clear and precise communication. Relying on the client's children for interpretation may not guarantee accurate or confidential communication. Asking the nurse to interpret can lead to miscommunication or misunderstanding of important medical information. Providing translation services for a nominal fee to clients may not always be feasible or culturally appropriate. Regularly evaluating the client's understanding helps ensure that information is effectively communicated and comprehended.

4. When assessing a client with sinusitis, which technique should the nurse use to identify manifestations of this disorder?

• A. Percussion of the frontal sinuses
• B. Auscultation of the trachea
• C. Inspection of the nasal mucosa
• D. Palpation of the orbital areas

Correct answer: D

Rationale: Sinusitis is an inflammation of the sinus cavities, which can cause tenderness and pain around the eyes (orbital areas). Palpation of the orbital areas can help identify tenderness and swelling associated with sinusitis. Auscultation of the trachea and percussion of the frontal sinuses are not relevant assessment techniques for sinusitis. Inspection of the nasal mucosa may reveal signs of inflammation, but palpation of the orbital areas is a more direct method to assess for tenderness and swelling in this specific condition.

5. During the assessment of a client receiving packed RBCs, which finding indicates fluid overload?

• A. Low back pain.
• B. Dyspnea.
• C. Hypotension.
• D. Thready pulse.

Correct answer: B

Rationale: Dyspnea is a key finding indicating fluid overload in a client receiving packed RBCs. Fluid overload can lead to pulmonary edema, causing difficulty breathing or shortness of breath (dyspnea). Low back pain is not typically associated with fluid overload but can be more related to musculoskeletal issues. Hypotension and thready pulse are more indicative of hypovolemia (low fluid volume), not fluid overload.

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