Nursing Elites

1. A nurse is assigned to care for four clients. Which client should the nurse assess first?

• A. A client with chest pain and shortness of breath
• B. A client with a fever of 100°F
• C. A client scheduled for surgery
• D. A client with stable vital signs

Correct answer: A

Rationale: The correct answer is A. Chest pain and shortness of breath are symptoms that could indicate a life-threatening condition such as a heart attack or pulmonary embolism. Therefore, this client should be assessed first to ensure prompt intervention and treatment. Choice B, a client with a fever of 100°F, may indicate an infection but is not immediately life-threatening compared to the symptoms of chest pain and shortness of breath. Choice C, a client scheduled for surgery, is not an immediate priority unless there are specific preoperative assessments or interventions required. Choice D, a client with stable vital signs, does not indicate an urgent need for assessment compared to the client with chest pain and shortness of breath.

2. A client with HIV-1 starting therapy with ritonavir and zidovudine asks why both medications are necessary. What explanation should the nurse provide?

• A. Taking two medications ensures a faster recovery.
• B. The medications work best together to improve your immune system.
• C. Taking the 2 medications together keeps you from becoming resistant to either of them.
• D. These medications target different parts of the virus.

Correct answer: C

Rationale: The correct answer is C because taking two medications together helps prevent the development of drug resistance in HIV treatment. Choice A is incorrect because the primary goal of combination therapy is not necessarily a faster recovery. Choice B is incorrect as the main purpose of combining medications in HIV treatment is to prevent resistance rather than improving the immune system. Choice D is incorrect because while it is true that the medications may target different parts of the virus, the main reason for using both together is to prevent resistance.

3. A nurse is assessing a client following a head injury and a brief loss of consciousness. Which of the following findings should the nurse report to the provider?

• A. Glasgow Coma Scale (GCS) score of 12
• B. Edematous bruise on the forehead
• C. Small drops of clear fluid in the left ear
• D. Pupils are 4 mm and reactive to light

Correct answer: C

Rationale: The correct answer is C. Clear fluid draining from the ear may indicate a cerebrospinal fluid (CSF) leak, which is a serious complication following a head injury. Reporting this finding is crucial as it may require immediate medical intervention to prevent further complications. Choices A, B, and D are not as concerning as a CSF leak. A GCS score of 12 is relatively high, indicating a mild level of consciousness alteration. An edematous bruise on the forehead is a common physical finding after a head injury. Pupils that are 4 mm and reactive to light suggest normal pupillary function.

4. While obtaining the health and medication history of a client with a respiratory infection, the nurse learns that the client developed a rash the last time she took an antibiotic despite not being aware of any allergies. What information should the nurse provide to the client?

• A. Document the exact medication taken
• B. Ignore the symptom
• C. Stop taking antibiotics
• D. Continue with the current medication

Correct answer: A

Rationale: The correct answer is to instruct the client to document the exact medication taken. This is crucial for preventing future allergic reactions. By knowing the specific antibiotic that caused the rash, healthcare providers can avoid prescribing it again, reducing the risk of an allergic response. Choice B, 'Ignore the symptom,' is incorrect as ignoring a potential allergic reaction can lead to more severe complications. Choice C, 'Stop taking antibiotics,' is not advisable without proper guidance from a healthcare provider. Choice D, 'Continue with the current medication,' is also not recommended when there is a history of a rash related to antibiotic use.

5. What are the signs of infection that should be monitored in a postoperative patient?

• A. Fever and chills
• B. All of the above
• C. Increased pain or tenderness
• D. Redness, swelling, and warmth at the surgical site

Correct answer: D

Rationale: The correct answer is D: 'Redness, swelling, and warmth at the surgical site.' These are specific signs of infection at the surgical site that a nurse should monitor for in a postoperative patient. While fever, chills, and increased pain can also indicate infection, the most direct signs are redness, swelling, and warmth at the surgical site. Therefore, 'D' is the best choice as it directly relates to the site of the surgery and is crucial to monitor for potential postoperative infections.

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