Nursing Elites

1. Patients are coming into the emergency room as a result of an apartment house fire. You are examining a patient who is in distress but has no visible burn marks. You suspect that she is suffering from inhalation burns. Which of the following signs would NOT be associated with inhalation burns?

• A. Singed nasal hairs
• B. Conjunctivitis
• C. Hoarseness
• D. Clear sputum

Correct answer: D

Rationale: Clear sputum would not be associated with inhalation burns. Inhalation burns typically present with symptoms like singed nasal hairs, conjunctivitis, hoarseness, and possibly soot in sputum due to smoke inhalation. Clear sputum suggests that there is no significant inflammation or injury to the respiratory tract, which is not consistent with the typical findings in inhalation burns. The other choices are associated with inhalation burns: singed nasal hairs can occur due to exposure to hot air or gases, conjunctivitis can result from irritating substances in smoke, and hoarseness can be due to airway irritation.

2. What is the primary action a healthcare professional should take when a patient with a suspected myocardial infarction (MI) arrives in the emergency department?

• A. Apply a cold compress to the chest
• B. Administer oxygen and obtain an electrocardiogram (ECG)
• C. Encourage the patient to walk to reduce anxiety
• D. Provide a high-carbohydrate meal

Correct answer: B

Rationale: Administering oxygen and obtaining an ECG are crucial initial steps when managing a suspected myocardial infarction (MI). Oxygen helps improve oxygenation to the heart muscle, while an ECG is essential to diagnose an MI promptly. Applying a cold compress, encouraging the patient to walk, or providing a high-carbohydrate meal are not appropriate actions in the initial management of a suspected MI. Applying a cold compress can delay necessary interventions, encouraging the patient to walk may worsen the condition, and providing a high-carbohydrate meal is irrelevant to the immediate needs of a patient with a suspected MI.

3. The nurse and UAP enter a client's room and find the client lying on the bed. The nurse determines that the client is unresponsive. Which instruction should the nurse give the UAP first?

• A. Obtain emergency help
• B. Feel for a carotid pulse
• C. Bring a glucometer to the room
• D. Check the blood pressure

Correct answer: A

Rationale: The correct answer is to instruct the UAP to obtain emergency help first. In a situation where a client is unresponsive, the priority is to ensure that help is summoned promptly. This allows for the availability of necessary resources and assistance for resuscitation or other emergency interventions. Feeling for a carotid pulse or checking the blood pressure can be important assessments but are secondary to obtaining immediate help. Bringing a glucometer to the room, while relevant in certain situations, is not the priority when the client's unresponsiveness indicates a need for urgent intervention.

4. When administering IV fluids to a client with a history of congestive heart failure (CHF), what is the nurse's primary concern?

• A. Monitoring for signs of fluid overload.
• B. Ensuring the client receives enough fluids to prevent dehydration.
• C. Preventing electrolyte imbalances.
• D. Maintaining the prescribed rate of fluid administration.

Correct answer: A

Rationale: The primary concern when administering IV fluids to a client with a history of congestive heart failure (CHF) is monitoring for signs of fluid overload. Clients with CHF are particularly vulnerable to fluid overload, which can exacerbate their condition. Signs of fluid overload include edema and difficulty breathing. Therefore, the nurse must closely monitor these signs to prevent worsening of the client's condition. Choices B, C, and D are incorrect because while ensuring hydration, preventing electrolyte imbalances, and maintaining the prescribed rate of fluid administration are important, they are secondary concerns compared to the critical task of monitoring for fluid overload in a client with CHF.

5. When caring for a patient with a fresh tracheostomy, what is the nurse’s first priority?

• A. Providing humidified oxygen
• B. Ensuring the tracheostomy ties are secure
• C. Suctioning the tracheostomy tube as needed
• D. Monitoring for signs of infection

Correct answer: B

Rationale: The correct answer is B: Ensuring the tracheostomy ties are secure. This is the nurse's first priority because it is critical to prevent accidental decannulation, which could compromise the patient’s airway. Providing humidified oxygen, suctioning the tracheostomy tube, and monitoring for signs of infection are important aspects of care but ensuring the tracheostomy ties' security takes precedence to maintain the patient's airway.

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