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 reviewing the laboratory results for a client who is at 29 weeks of gestation. Which of the following results should the nurse report to the provider?

• A. WBC count 11,000/mm³
• B. Hgb 11.2 g/dL
• C. Hct 34%
• D. Platelets 140,000/mm³

Correct answer: D

Rationale: A platelet count of 140,000/mm³ is at the lower end of the normal range but can be concerning in pregnancy, especially if there are signs of thrombocytopenia or bleeding. Thrombocytopenia in pregnancy can lead to complications such as bleeding during childbirth or excessive bleeding postpartum. The other laboratory values mentioned are within normal ranges for pregnancy and do not typically raise immediate concerns. High WBC counts can be a normal response to pregnancy, hemoglobin levels around 11.2 g/dL and hematocrit levels around 34% are also considered normal in the third trimester.

3. A nurse is caring for a toddler diagnosed with respiratory syncytial virus (RSV). Which of the following actions should the nurse take?

• A. Use a designated stethoscope when caring for the toddler
• B. Wear an N95 respirator mask
• C. Remove the disposable gown after leaving the toddler’s room
• D. Place the toddler in a room with negative air pressure

Correct answer: A

Rationale: Using a designated stethoscope is the correct action when caring for a toddler diagnosed with RSV. This measure helps prevent the spread of infection to other clients by reducing the risk of contamination. Wearing an N95 respirator mask is not necessary for routine care of a toddler with RSV unless performing aerosol-generating procedures. Removing the disposable gown after leaving the toddler's room is important for infection control but not specific to RSV care. Placing the toddler in a room with negative air pressure is not a standard practice for managing RSV in toddlers.

4. A nurse reviewing a patient’s care plan notes a goal of 'Patient will ambulate 50 feet three times in the hallway today.' Which domain of Bloom’s taxonomy is this goal in?

• A. Affective domain
• B. Physical domain
• C. Psychomotor domain
• D. Cognitive domain

Correct answer: C

Rationale: The psychomotor domain involves physical activity and motor skills, such as ambulation, making it the correct domain for this goal. Choices A, B, and D are incorrect: Affective domain focuses on emotions and attitudes, physical domain is not a recognized domain in Bloom's taxonomy, and cognitive domain pertains to knowledge and intellectual skills, none of which directly relate to the physical act of ambulation.

5. A nurse is reviewing the laboratory results for a client who has end-stage liver disease. Which of the following findings should the nurse expect?

• A. Elevated albumin
• B. Elevated ammonia
• C. Decreased total bilirubin
• D. Decreased prothrombin time

Correct answer: B

Rationale: In end-stage liver disease, the liver's inability to convert ammonia into urea leads to elevated ammonia levels. Elevated ammonia levels can result in hepatic encephalopathy, a serious complication. Therefore, the correct answer is B. Elevated albumin (Choice A) is not typically seen in end-stage liver disease as liver dysfunction often leads to decreased albumin levels. Decreased total bilirubin (Choice C) is unlikely in end-stage liver disease, as bilirubin levels tend to be elevated due to impaired liver function. Decreased prothrombin time (Choice D) is also not expected in end-stage liver disease, as impaired liver function results in prolonged prothrombin time.

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