Nursing Elites

1. A nurse in the emergency department is caring for a client who has full-thickness burns of the thorax and upper torso. After securing the client's airway, which of the following is the nurse's priority intervention?

• A. Providing pain management.
• B. Offering emotional support.
• C. Preventing infection.
• D. Initiating IV fluids.

Correct answer: D

Rationale: After securing the airway, initiating IV fluids is the priority to prevent hypovolemic shock in clients with severe burns. IV fluids help maintain circulating volume and prevent a drop in blood pressure due to fluid loss. Providing pain management, offering emotional support, and preventing infection are important aspects of care but are secondary to ensuring adequate fluid resuscitation in clients with severe burns.

2. A nurse is caring for a client with dementia who frequently attempts to get out of bed unsupervised. What is the best intervention?

• A. Use restraints to prevent the client from getting out of bed
• B. Encourage family members to stay with the client at all times
• C. Use a bed exit alarm system
• D. Keep the client's room dark and quiet to reduce stimulation

Correct answer: C

Rationale: The best intervention for a client with dementia who frequently attempts to get out of bed unsupervised is to use a bed exit alarm system (Choice C). A bed exit alarm can alert staff when the client tries to leave the bed, helping to prevent falls. Using restraints (Choice A) is not recommended as it can lead to physical and psychological harm. While having family members present (Choice B) can be beneficial, it may not be feasible at all times. Keeping the client's room dark and quiet (Choice D) may not address the immediate safety concern of the client attempting to get out of bed.

3. A nurse is collecting data from a male client who is scheduled for a left inguinal herniorrhaphy. Which of the following findings is the priority for the nurse to report to the provider?

• A. High blood pressure
• B. Decreased bowel sounds
• C. Constipation
• D. Difficulty urinating

Correct answer: D

Rationale: The correct answer is 'Difficulty urinating.' This finding is crucial to report promptly as it can indicate a complication, such as urinary retention or injury to the urinary tract, which are significant concerns post-hernia surgery. High blood pressure (Choice A) may require monitoring but is not as urgent as difficulty urinating. Decreased bowel sounds (Choice B) and constipation (Choice C) are common after surgery and may resolve with appropriate interventions but are not as critical as addressing difficulty urinating.

4. How should a healthcare professional assess a patient with hyperkalemia?

• A. Monitor ECG and administer insulin
• B. Monitor blood glucose levels and provide fluids
• C. Monitor for muscle weakness and administer calcium gluconate
• D. Monitor electrolyte levels and provide potassium supplements

Correct answer: A

Rationale: Corrected Question: When assessing a patient with hyperkalemia, monitoring the ECG and administering insulin are crucial steps. Hyperkalemia can affect the heart's function, leading to life-threatening arrhythmias. Monitoring the ECG helps in identifying any cardiac abnormalities associated with high potassium levels. Administering insulin, along with glucose, helps shift potassium from the bloodstream into the cells, temporarily lowering the potassium levels. Choice B is incorrect because monitoring blood glucose levels and providing fluids are not the primary interventions for hyperkalemia. Choice C is incorrect as monitoring for muscle weakness and administering calcium gluconate are not the first-line treatments for hyperkalemia. Calcium gluconate may be used in specific situations to stabilize cardiac cell membranes in severe cases of hyperkalemia. Choice D is incorrect because monitoring electrolyte levels and providing potassium supplements would worsen hyperkalemia, as the patient already has elevated potassium levels and does not require additional potassium supplementation.

5. What is the priority intervention for sepsis?

• A. Administer IV antibiotics
• B. Monitor blood pressure
• C. Administer fluids
• D. All of the above

Correct answer: D

Rationale: In the management of sepsis, prompt intervention is crucial. Administering IV antibiotics is essential to target the underlying infection. Monitoring blood pressure helps assess the patient's hemodynamic status. Administering fluids is vital to maintain adequate perfusion. Therefore, all the options are integral components of the initial management of sepsis, making 'All of the above' the correct answer. Choosing any single intervention over the others may delay optimal care and compromise patient outcomes.

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