Nursing Elites

1. When caring for a client with a wound infection, what is the most important nursing action?

• A. Change the dressing every 4 hours
• B. Perform a wound culture before administering antibiotics
• C. Cleanse the wound with alcohol-based solutions
• D. Apply a wet-to-dry dressing to the wound

Correct answer: B

Rationale: Performing a wound culture before administering antibiotics is crucial in identifying the specific infecting organism and choosing the most effective antibiotic treatment. Changing the dressing every 4 hours (choice A) may be too frequent and can disrupt the wound healing process. Cleansing the wound with alcohol-based solutions (choice C) can be too harsh and may delay healing. Applying a wet-to-dry dressing (choice D) can cause trauma to the wound bed and is not recommended for infected wounds.

2. Which of the following interventions is most appropriate for a client with left-leg weakness who is learning to use a cane?

• A. Maintain two points of support on the floor at all times
• B. Use the cane on the weak side of the body
• C. Advance the cane and the strong leg simultaneously
• D. Advance the cane 30 to 45 cm (12-18 in) with each step

Correct answer: A

Rationale: The most appropriate intervention for a client with left-leg weakness learning to use a cane is to maintain two points of support on the floor at all times. This ensures stability and helps distribute weight evenly between the legs, reducing the risk of falls. Using the cane on the weak side of the body (Choice B) may not provide adequate support. Advancing the cane and the strong leg simultaneously (Choice C) can lead to imbalance and increases the risk of falls. Advancing the cane too far with each step (Choice D) can also compromise balance and stability.

3. The nurse is performing triage on a group of clients in the emergency department. Which of the following clients should the nurse see first?

• A. A 12-year-old oozing blood from a laceration on the left thumb due to a cut from a rusty metal can
• B. A 19-year-old with a fever of 103.8°F who is able to identify her sister but not the place and time
• C. A 49-year-old with a compound fracture of the right leg who is complaining of severe pain
• D. A 65-year-old with a flushed face, dry mucous membranes, and a blood sugar of 470 mg/dL

Correct answer: B

Rationale: The correct answer is B. A 19-year-old with a fever of 103.8°F who is confused and unable to orient to place and time likely has a severe infection or a serious medical condition affecting the central nervous system. This client needs immediate attention as altered mental status combined with a high fever can indicate a life-threatening situation. Choices A, C, and D present important conditions that require medical care, but they are not as urgent as the 19-year-old with a high fever and confusion. The 12-year-old with a laceration may require treatment for bleeding and a tetanus shot, the 49-year-old with a compound fracture needs urgent orthopedic intervention, and the 65-year-old with a high blood sugar is concerning for hyperglycemia but can wait momentarily compared to the client with a fever and altered mental status.

4. What are the nursing priorities for a patient experiencing an asthma exacerbation?

• A. Administer a bronchodilator
• B. Encourage deep breathing
• C. Provide oxygen therapy
• D. Monitor oxygen saturation

Correct answer: A

Rationale: The correct nursing priority for a patient experiencing an asthma exacerbation is to administer a bronchodilator. Bronchodilators help in relieving bronchoconstriction and improving breathing. While encouraging deep breathing, providing oxygen therapy, and monitoring oxygen saturation are essential aspects of managing asthma exacerbation, the priority is to administer a bronchodilator to address the acute bronchoconstriction.

5. A nurse is caring for a client who is 2 hours postoperative following an appendectomy. Which of the following findings should the nurse report to the provider?

• A. Urine output of 20 mL/hr.
• B. Temperature of 36.5°C (97.7°F).
• C. Sanguineous drainage on the surgical dressing.
• D. WBC count of 9,000/mm3.

Correct answer: A

Rationale: The correct answer is A: Urine output of 20 mL/hr. A urine output less than 30 mL/hr can indicate decreased renal perfusion, potentially due to hypovolemia or other issues, and should be reported to the provider. B: A temperature of 36.5°C (97.7°F) falls within the normal range and does not require immediate reporting. C: Sanguineous drainage on the surgical dressing is expected in the early postoperative period and should be monitored but does not need immediate reporting unless excessive. D: A WBC count of 9,000/mm3 is within the normal range and does not indicate an immediate concern.

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