Nursing Elites

1. The nurse is preparing a client for surgery who was admitted to the emergency center following a motor vehicle collision. The client has an open fracture of the femur and is bleeding moderately from the bone protrusion site.

• A. Ensure the client is NPO and document the last meal.
• B. Administer pain medication as prescribed.
• C. Apply a sterile dressing to the wound site.
• D. Notify the healthcare provider of the client’s medication history.

Correct answer: D

Rationale: In this scenario, the priority action is to notify the healthcare provider of the client's medication history. This is important because understanding the client’s medication history, especially if they are taking anticoagulants or other medications that could affect bleeding and surgery, is crucial in ensuring safe management of the client's condition. Option A, ensuring the client is NPO and documenting the last meal, is important but not the priority in this situation. Administering pain medication (Option B) should only be done after ensuring the client's safety and stability. Applying a sterile dressing (Option C) is also important but not as critical as informing the healthcare provider of the medication history.

2. What is the best position for a client experiencing a nosebleed?

• A. Sitting up and leaning forward
• B. Lying flat with a pillow under the head
• C. Sitting up and leaning back
• D. Lying on the side with the head elevated

Correct answer: A

Rationale: The best position for a client experiencing a nosebleed is sitting up and leaning forward. This position helps prevent blood from flowing down the throat and reduces the risk of aspiration. Choice B is incorrect as lying flat can lead to blood flowing down the throat. Choice C is also incorrect because leaning back may cause blood to flow backward into the throat. Choice D is incorrect as lying on the side with the head elevated is not the optimal position to manage a nosebleed effectively.

3. A male client with heart failure calls the clinic and reports that he cannot put his shoes on because they are too tight. Which additional information should the nurse obtain?

• A. What time he took his medication?
• B. Has his weight changed in the last several days?
• C. Is he still able to tighten his belt buckle?
• D. How many hours he slept last night?

Correct answer: B

Rationale: The correct answer is B: 'Has his weight changed in the last several days?' Sudden weight gain can indicate fluid retention, which is a common symptom of worsening heart failure. The inability to put on tight shoes can be due to fluid retention leading to swelling in the feet and ankles. Choices A, C, and D do not directly address the potential fluid retention issue and are less relevant in this scenario.

4. A female client who was involved in a motor vehicle collision is admitted with a fractured left femur which is immobilized using a fracture traction splint in preparation for an open reduction internal fixation (ORIF). The nurse determines that her distal pulses are diminished in the left foot. Which interventions should the nurse implement? (Select all that apply)

• A. Verify pedal pulses using a doppler pulse device.
• B. Monitor left leg for pain, pallor, paresthesia, paralysis, pressure.
• C. Evaluate the application of the splint to the left leg.
• D.

Correct answer: C

Rationale: It is crucial for the nurse to evaluate the application of the splint to the left leg in a client with diminished distal pulses. This assessment helps ensure that the splint is not causing any compromise to circulation. Verifying pulses and monitoring for leg conditions are important interventions but do not directly address the issue with the splint application in this scenario, making them less relevant.

5. Which of the following is a priority assessment for a client receiving intravenous vancomycin?

• A. Respiratory rate
• B. Blood pressure
• C. Urine output
• D. Hearing acuity

Correct answer: D

Rationale: The correct answer is D, Hearing acuity. Vancomycin is known to cause ototoxicity, which can result in hearing loss. Monitoring the client's hearing acuity is crucial to detect any early signs of ototoxicity. Assessing respiratory rate, blood pressure, and urine output are important assessments in general patient care but are not the priority when specifically monitoring for vancomycin-induced ototoxicity.

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