Nursing Elites

1. During a mass casualty event, a nurse is caring for multiple clients. Which of the following clients is the nurse’s priority?

• A. A client who received crush injuries to the chest and abdomen and is expected to die.
• B. A client who has a 4-inch laceration to the head.
• C. A client who has partial-thickness and full-thickness burns to his face, neck, and chest.
• D. A client who has a fractured fibula and tibia.

Correct answer: C

Rationale: During a mass casualty event, the priority client for the nurse is the one with partial-thickness and full-thickness burns to the face, neck, and chest. Clients with severe burns in critical areas require immediate attention due to the potential for life-threatening complications such as airway compromise, fluid loss, and infection. Crush injuries and fractures, although serious, are generally less urgent in comparison and can be managed after addressing the burns. Therefore, the client with burns to the face, neck, and chest should be the nurse's priority over the other clients described.

2. A male client presents to the clinic stating that he has a high-stress job and is having difficulty falling asleep at night. The client reports having a constant headache and is seeking medication to help with sleep. Which intervention should the nurse implement?

• A. Determine the client's sleep and activity pattern
• B. Obtain a prescription for the client to take when stressed
• C. Refer the client for a sleep study and neurological follow-up
• D. Teach coping strategies to use when feeling stressed

Correct answer: A

Rationale: The correct intervention for the nurse to implement in this scenario is to determine the client's sleep and activity pattern. By assessing the client's patterns, the nurse can identify factors contributing to the sleep issues and tailor appropriate interventions. Choice B is incorrect because prescribing medication without a comprehensive assessment is not the initial step. Choice C is unnecessary at this stage as the client's symptoms are likely related to stress rather than a neurological disorder. Choice D, while important, should come after understanding the client's sleep patterns to provide holistic care. Therefore, option A is the best choice to address the client's sleep difficulties and headaches effectively.

3. A nurse in a provider's office is preparing to assess a young adult client's musculoskeletal system as part of a comprehensive physical examination. Which of the following findings should the nurse expect?

• A. Concave thoracic spine posteriorly
• B. Exaggerated lumbar curvature
• C. Concave lumbar spine posteriorly
• D. Exaggerated thoracic curvature

Correct answer: B

Rationale: When assessing a young adult's musculoskeletal system, the nurse should expect an exaggerated lumbar curvature (lordosis). This is a normal finding in young adults due to the natural curvature of the spine. Concave thoracic spine posteriorly (choice A) and concave lumbar spine posteriorly (choice C) are not typical findings as the spine should have normal curvatures. Exaggerated thoracic curvature (choice D) is also not a typical finding in young adults.

4. When replacing a client's surgical dressing, what should the nurse do?

• A. Don sterile gloves to remove the old dressing
• B. Wash hands thoroughly before removing the old dressing
• C. Use sterile gloves to remove the old dressing
• D. Apply a new dressing before removing the old one

Correct answer: C

Rationale: When replacing a client's surgical dressing, the nurse should use sterile gloves to remove the old dressing. Sterile technique is essential to prevent introducing infection to the wound. Choice A is incorrect because clean gloves are not sufficient; sterile gloves are necessary to maintain asepsis. Choice B, washing hands, is an important step before and after the procedure to maintain hand hygiene, but sterile gloves are required during the dressing change. Choice D is incorrect because a new dressing should only be applied after the old one has been removed to prevent contamination and ensure proper wound care.

5. A client has been admitted to the hospital with severe diarrhea. The nurse should monitor the client for which complication?

• A. Metabolic acidosis
• B. Metabolic alkalosis
• C. Hyperkalemia
• D. Hypercalcemia

Correct answer: A

Rationale: Severe diarrhea can lead to metabolic acidosis due to the loss of bicarbonate. When there is excessive loss of bicarbonate through diarrhea, the pH of the blood decreases, leading to metabolic acidosis. Metabolic alkalosis (Choice B) is not typically associated with severe diarrhea as it involves elevated pH and bicarbonate levels. Hyperkalemia (Choice C) is less likely with severe diarrhea as potassium is often lost along with fluids. Hypercalcemia (Choice D) is not a common complication of severe diarrhea; instead, hypocalcemia may occur due to malabsorption of calcium.

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