Nursing Elites

1. The client has jaundice, elevated liver enzymes, and an elevated serum bilirubin. What color urine does the nurse expect to find?

• A. Pink-tinged
• B. Straw-colored
• C. Clear
• D. Dark amber

Correct answer: D

Rationale: The correct answer is dark amber. In jaundice, the elevated bilirubin levels are excreted in the urine, giving it a dark amber color. Choices A, B, and C are incorrect because in jaundice, the urine typically appears dark amber due to the presence of elevated bilirubin, not pink-tinged, straw-colored, or clear.

2. The factor that most determines drug distribution is:

• A. vascular perfusion of the tissue or organ.
• B. salt form.
• C. drug interactions.
• D. steady state.

Correct answer: A

Rationale: The correct answer is 'vascular perfusion of the tissue or organ.' Drug distribution is primarily determined by how well the circulatory system delivers the drug to various tissues and organs. Adequate perfusion ensures proper distribution of the drug throughout the body. While the salt form (choice B), drug interactions (choice C), and steady state (choice D) can influence drug efficacy and metabolism, they are not as crucial as vascular perfusion for the initial distribution of a drug.

3. Ten-year-old Jackie is admitted to the hospital with a medical diagnosis of Rheumatic Fever. She relates a history of 'a sore throat about a month ago.' Bed rest with bathroom privileges is prescribed. Which of the following nursing assessments should be given the highest priority when assessing Jackie's condition?

• A. her response to hospitalization
• B. the presence of a macular rash on her trunk
• C. her cardiac status
• D. the presence of polyarthritis and joint pain

Correct answer: C

Rationale: Monitoring Jackie's cardiac status is of the highest priority in a patient with rheumatic fever. Rheumatic fever can lead to permanent cardiac damage, making it crucial to closely monitor the heart. Assessing for signs of carditis, such as murmurs or other cardiac symptoms, is essential. The second priority is evaluating joint symptoms for the presence of polyarthritis and pain, which are common manifestations of rheumatic fever. While assessing Jackie's response to hospitalization is important for her emotional well-being, it is not the highest priority. The presence of a macular rash, although relevant, is not as high a priority as monitoring cardiac status or assessing joint symptoms.

4. The newborn nursery is filled to capacity. Which newborn should the nurse assess first?

• A. A three-hour-old just waking up after a period of sleep
• B. A two-day-old crying loudly
• C. A three-day-old two hours after circumcision
• D. A one-hour-old sucking his fist

Correct answer: A

Rationale: The most critical time for assessment in a newborn is during the second period of reactivity, which occurs approximately 3-5 hours after delivery. During this phase, newborns are more likely to gag on mucus and aspirate, making it crucial for the nurse to assess their respiratory status first. Choice A indicates a newborn in this critical phase, requiring immediate assessment for potential airway compromise or respiratory distress. Choices B, C, and D do not present an immediate need for assessment related to airway compromise or respiratory distress.

5. Why must the nurse be careful not to cut through or disrupt any tears, holes, bloodstains, or dirt present on the clothing of a client who has experienced trauma?

• A. The clothing is the property of another and must be treated with care.
• B. Such care facilitates repair and salvage of the clothing.
• C. The clothing of a trauma victim is potential evidence with legal implications.
• D. Such care decreases trauma to the family members receiving the clothing.

Correct answer: C

Rationale: The correct answer is C. Trauma in any client, living or dead, has potential legal and/or forensic implications. Clothing, patterns of stains, and debris are sources of potential evidence and must be preserved. Nurses must be aware of state and local regulations that require mandatory reporting of cases of suspected child and elder abuse, accidental death, and suicide. Each Emergency Department has written policies and procedures to assist nurses and other health care providers in making appropriate reports. Physical evidence is real, tangible, or latent matter that can be visualized, measured, or analyzed. Emergency Department nurses can be called on to collect evidence. Health care facilities have policies governing the collection of forensic evidence. The chain of evidence custody must be followed to ensure the integrity and credibility of the evidence. The chain of evidence custody is the pathway that evidence follows from the time it is collected until it has served its purpose in the legal investigation of an incident. Choices A, B, and D are incorrect because they do not address the crucial aspect of preserving potential evidence with legal implications that may be present on the clothing of a trauma victim.

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