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 healthcare professional is reviewing the medical record of a client who is receiving furosemide. Which of the following laboratory values should the healthcare professional monitor while the client is taking this medication?

• A. Sodium
• B. Glucose
• C. Potassium
• D. Calcium

Correct answer: C

Rationale: The correct answer is C: Potassium. Furosemide is a diuretic that can cause potassium depletion due to increased urinary excretion. Monitoring potassium levels is crucial to prevent hypokalemia, which can lead to serious complications such as cardiac arrhythmias. Sodium (choice A) levels are not typically affected by furosemide. Glucose (choice B) monitoring is important with other medications like corticosteroids but is not directly related to furosemide use. Calcium (choice D) levels are not significantly impacted by furosemide.

3. A nurse is assisting with monitoring a client who is in labor and has spontaneous rupture of membranes following a vaginal examination. The provider reports the client's cervix is dilated to 1 cm with an unengaged presenting part. Which of the following actions should the nurse take?

• A. Encourage the client to bear down
• B. Apply the external fetal monitor
• C. Provide the client with fluids
• D. Administer IV fluids

Correct answer: B

Rationale: In this scenario, with the client's cervix dilated to only 1 cm and an unengaged presenting part, the priority action is to apply the external fetal monitor. This allows for continuous monitoring of the fetal heart rate during early labor, which is crucial for assessing fetal well-being. Encouraging the client to bear down is not appropriate at 1 cm dilation, as it may not be effective and can lead to exhaustion. Providing the client with fluids or administering IV fluids may be necessary for hydration, but the immediate concern is monitoring fetal well-being.

4. What are the complications of untreated hypertension?

• A. Heart disease and stroke
• B. Kidney failure and vision loss
• C. Pulmonary embolism and arrhythmias
• D. Blood clots and gastrointestinal bleeding

Correct answer: A

Rationale: The correct answer is A: 'Heart disease and stroke.' Untreated hypertension can lead to various complications, including heart disease and stroke. These are common outcomes of long-term high blood pressure. Choice B, 'Kidney failure and vision loss,' is incorrect as kidney failure and vision loss are more commonly associated with diabetic complications rather than untreated hypertension. Choice C, 'Pulmonary embolism and arrhythmias,' while serious, are not among the primary complications of untreated hypertension. Choice D, 'Blood clots and gastrointestinal bleeding,' are not typical complications of untreated hypertension but can occur due to other conditions such as blood clotting disorders or gastrointestinal diseases.

5. How should a healthcare provider assess and manage a patient with a potential myocardial infarction (MI)?

• A. Assess symptoms, monitor vital signs, order ECG
• B. Administer medications and monitor for pain
• C. Administer thrombolytics and oxygen therapy
• D. Educate patient on lifestyle changes

Correct answer: A

Rationale: Correct Answer: A. When assessing a patient with a potential myocardial infarction, it is crucial to assess symptoms, monitor vital signs like blood pressure and heart rate, and order an electrocardiogram (ECG) to evaluate for cardiac abnormalities. Choice B is incorrect because administering medications should be based on the findings of the assessment and diagnostic tests, not administered indiscriminately. Choice C is incorrect because the administration of thrombolytics and oxygen therapy should be based on specific criteria and should be done in a controlled setting. Choice D is incorrect as educating the patient on lifestyle changes is important for prevention but is not the immediate priority when managing a potential myocardial infarction.

Similar Questions