Nursing Elites

1. A nurse is assessing a postoperative patient for signs of infection. Which finding is most concerning?

• A. Mild redness at the incision site.
• B. Increased drainage from the surgical site.
• C. Fever of 101°F.
• D. Normal white blood cell count.

Correct answer: C

Rationale: A fever of 101°F is the most concerning finding when assessing a postoperative patient for signs of infection. Fever can indicate an inflammatory response to an infection, and in a postoperative patient, it can signal a surgical site infection or a systemic infection. Prompt attention is necessary to prevent complications such as sepsis. Mild redness at the incision site and increased drainage can be expected in the early postoperative period due to the normal healing process. A normal white blood cell count does not rule out infection as it can be influenced by various factors, and some infections may not initially cause a rise in white blood cells.

2. A family was referred to crisis intervention services after a natural disaster. One family member refuses to attend, stating, 'No way, I'm not crazy.' What is the nurse's best response?

• A. Don't worry now. The psychiatrists are well trained to help.
• B. Many times, disasters can create mental health problems, so you really should participate with your family.
• C. This will help your family communicate better.
• D. Seeking this kind of help does not mean that you have a mental illness; it is a short-term problem-solving technique.

Correct answer: D

Rationale: The nurse should reassure the family member that seeking help does not imply mental illness, but is part of coping with the disaster.

3. A patient with severe pain and leg swelling is admitted. What should the nurse assess for?

• A. Check for signs of deep vein thrombosis.
• B. Assess for compartment syndrome.
• C. Increase the patient's fluid intake.
• D. Prepare the patient for surgery to relieve pain.

Correct answer: B

Rationale: When a patient presents with severe pain and leg swelling, the nurse should assess for compartment syndrome. Compartment syndrome is a serious condition that can develop due to increased pressure within a muscle compartment, leading to compromised circulation and potential tissue damage. It is crucial to identify compartment syndrome promptly as it may require immediate intervention to prevent further complications. Checking for signs of deep vein thrombosis (Choice A) is also important in a patient with leg swelling, but in this scenario, the focus should be on assessing for compartment syndrome due to the severity of the symptoms. Increasing fluid intake (Choice C) may not address the underlying cause of the patient's symptoms. Preparing the patient for surgery (Choice D) without a comprehensive assessment and diagnosis is premature and may not be the appropriate initial intervention.

4. A community nurse is instructing a group of newly licensed nurses about diseases that require airborne precautions. Which of the following diseases should the nurse include?

• A. Rubella
• B. Pertussis
• C. Influenza
• D. Varicella

Correct answer: D

Rationale: The correct answer is D, Varicella. Varicella (chickenpox) is a disease that requires airborne precautions to prevent its spread. Airborne precautions are necessary to prevent transmission of pathogens that remain infectious over long distances when suspended in the air. Rubella, pertussis, and influenza do not require airborne precautions. Rubella and pertussis require droplet precautions, while influenza requires droplet and contact precautions. Therefore, Varicella is the only disease in the list that necessitates airborne precautions.

5. What are the main differences between a stroke caused by ischemia and one caused by hemorrhage?

• A. Blockage in a blood vessel supplying the brain
• B. Bleeding in the brain due to a ruptured aneurysm
• C. Administering thrombolytics if within the treatment window
• D. Avoiding anticoagulants and preparing for surgery

Correct answer: A

Rationale: The correct answer is A: "Blockage in a blood vessel supplying the brain." Ischemic stroke is caused by a blockage in a blood vessel supplying the brain, leading to reduced blood flow. Hemorrhagic stroke, on the other hand, is caused by bleeding in the brain due to a ruptured blood vessel. Choices B, C, and D are incorrect. Administering thrombolytics, avoiding anticoagulants, and preparing for surgery are specific management strategies that may apply to ischemic or hemorrhagic strokes but do not define the main differences between the two types of strokes.

Similar Questions