Nursing Elites

1. A nurse in the emergency department is caring for a patient who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the patient’s care, the nurse should identify which of the following risks as the priority for assessment and intervention?

• A. Infection
• B. Airway obstruction
• C. Fluid imbalance
• D. Pain management

Correct answer: B

Rationale: When a patient has extensive burns involving the head, neck, and chest, the priority concern is airway obstruction. The proximity of the burns to the airway can lead to swelling and compromise the patient's ability to breathe. In this situation, ensuring a clear airway and adequate oxygenation takes precedence over other risks such as infection, fluid imbalance, or pain management. While these are also important considerations in burn care, the immediate threat to the patient's life from airway compromise makes it the priority for assessment and intervention.

2. A nurse is caring for an older adult who has a nonpalpable skin lesion that is less than 0.5 cm (0.2 in) in diameter. Which of the following terms should the nurse use to document this finding?

• A. Papule
• B. Vesicle
• C. Macule
• D. Nodule

Correct answer: C

Rationale: The correct term the nurse should use to document this finding is 'Macule.' A macule is a flat, nonpalpable skin lesion that is smaller than 1 cm in diameter. In this case, the lesion described is less than 0.5 cm, making it appropriate to classify it as a macule. 'Papule' (Choice A) refers to a solid, elevated skin lesion, 'Vesicle' (Choice B) is a small fluid-filled blister, and 'Nodule' (Choice D) is a solid, elevated skin lesion that is larger and deeper than a papule, none of which accurately describe the lesion in question.

3. A nurse is caring for a laboring client and notes that the fetal heart rate begins to decelerate after the contraction has started. The lowest point of deceleration occurs after the peak of the contraction. What is the priority nursing action?

• A. Administer oxygen
• B. Change the client's position
• C. Increase IV fluids
• D. Call the healthcare provider

Correct answer: B

Rationale: Late decelerations are caused by uteroplacental insufficiency, indicating that the fetus is not receiving adequate oxygen during contractions. This is an emergency that requires prompt intervention. Changing the client's position helps improve placental blood flow, reducing stress on the fetus. Administering oxygen may be necessary if changing position does not resolve the decelerations. Increasing IV fluids is not the priority in this situation as it won't directly address the cause of late decelerations. Calling the healthcare provider should be done after immediate interventions like changing the client's position have been implemented and assessed.

4. A client is taking levothyroxine. Which of the following findings should indicate that the medication is effective?

• A. Weight loss
• B. Decreased blood pressure
• C. Absence of seizures
• D. Decreased inflammation

Correct answer: A

Rationale: The correct answer is A: Weight loss. Levothyroxine is used to treat hypothyroidism, which is characterized by symptoms such as weight gain. Therefore, weight loss in a client taking levothyroxine indicates that the medication is effective in managing hypothyroidism. Choices B, C, and D are incorrect because levothyroxine primarily affects thyroid function and metabolism, not blood pressure, seizures, or inflammation.

5. When teaching a client about the use of trazodone, what should be included?

• A. It can cause sedation
• B. It is a stimulant
• C. It has no side effects
• D. It should be taken with food

Correct answer: A

Rationale: The correct answer is A. Trazodone can cause sedation, so clients should be cautioned about activities requiring alertness, like driving. Choice B is incorrect because trazodone is not a stimulant; it is actually a sedating antidepressant. Choice C is incorrect as all medications have potential side effects. Choice D is not specifically indicated for trazodone; the client should follow the prescribing healthcare provider's instructions regarding food intake.

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