Nursing Elites

1. A healthcare provider is assisting with mass casualty triage following an explosion at a local factory. Which of the following clients should the healthcare provider identify as the priority?

• A. A client who has massive head trauma
• B. A client who has full-thickness burns to the face and trunk
• C. A client with indications of hypovolemic shock
• D. A client with an open fracture of the lower extremity

Correct answer: C

Rationale: In a mass casualty situation, a client with hypovolemic shock should be the priority as they require immediate intervention to restore fluid volume and prevent further deterioration. Hypovolemic shock can lead to organ failure and death if not addressed promptly. While clients with other severe conditions like massive head trauma, full-thickness burns, or an open fracture also need urgent care, hypovolemic shock directly threatens the client's life due to inadequate circulating blood volume. Therefore, stabilizing the client with indications of hypovolemic shock takes precedence over others in this scenario.

2. A nurse in an emergency department is assessing a client who reports ingesting thirty diazepam tablets. After securing the client's airway and initiating an IV, which of the following actions should the nurse do next?

• A. Monitor the client's IV site for thrombophlebitis.
• B. Administer flumazenil to the client.
• C. Evaluate the client for further suicidal behavior.
• D. Initiate seizure precautions for the client.

Correct answer: B

Rationale: Administering flumazenil is the priority to reverse the effects of diazepam overdose. Flumazenil is a specific benzodiazepine receptor antagonist that can rapidly reverse the sedative effects of diazepam. Monitoring the IV site for thrombophlebitis is important but not the immediate priority in this situation. Evaluating the client for further suicidal behavior is important for comprehensive care but is not the most urgent action at this moment. Initiating seizure precautions may be necessary, but the priority is to counteract the sedative effects of diazepam with flumazenil.

3. A nurse is providing teaching to a client who has a new prescription for ferrous sulfate. Which of the following instructions should the nurse include?

• A. Take this medication with orange juice to increase absorption.
• B. Take this medication on an empty stomach.
• C. Take this medication with milk if it causes stomach upset.
• D. Take this medication at bedtime.

Correct answer: A

Rationale: The correct instruction for a client prescribed ferrous sulfate is to take the medication with orange juice to enhance absorption. Orange juice is recommended because of its vitamin C content, which aids in the absorption of iron. Choice B, taking the medication on an empty stomach, is incorrect because ferrous sulfate is better absorbed with food. Choice C, taking the medication with milk if it causes stomach upset, is incorrect as calcium in milk can interfere with iron absorption. Choice D, taking the medication at bedtime, is incorrect as it is usually recommended to take iron supplements between meals or with food to enhance absorption.

4. A nurse is providing teaching to parents of a newborn about genetic screening. Which of the following statements should the nurse include in the teaching?

• A. You should keep your baby's identification band on at all times.
• B. It is safe to leave your baby unattended in the room.
• C. Identification bands should be applied immediately after birth.
• D. Avoid public announcements about your baby's birth.

Correct answer: D

Rationale: The correct answer is D because avoiding public announcements about the baby's birth is crucial to reduce the risk of newborn abduction. Public announcements can attract unwanted attention and potentially jeopardize the safety of the newborn. Choices A, B, and C are incorrect. Choice A is incorrect because the baby's identification band should be kept on at all times for security purposes. Choice B is incorrect because leaving the baby unattended in the room can pose risks. Choice C is incorrect because identification bands are usually applied immediately after birth, not after the first bath.

5. A healthcare professional is assessing a client who is receiving opioid analgesics. Which of the following findings should the professional report to the provider?

• A. Oxygen saturation of 94%
• B. Blood pressure of 110/70 mm Hg
• C. Respiratory rate of 12/min
• D. Heart rate of 88/min

Correct answer: C

Rationale: A respiratory rate of 12/min may indicate respiratory depression, a potential side effect of opioid analgesics. Respiratory depression can be a serious complication that requires immediate intervention. Monitoring the respiratory rate is crucial in clients receiving opioids to prevent adverse events. Oxygen saturation, blood pressure, and heart rate are important parameters to assess, but a low respiratory rate is a more critical finding that warrants immediate reporting to the healthcare provider.

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