Nursing Elites

1. Which client should the nurse see first?

• A. Recurring crushing chest pain
• B. Needing an IV for surgery in 5 minutes
• C. Needing PCA morphine for pain control post-hysterectomy
• D. Waiting to get back to bed after sitting in a chair for 30 minutes

Correct answer: A

Rationale: The client presenting with recurring crushing chest pain should be seen first as this symptom could indicate a myocardial infarction (MI), which is a life-threatening condition requiring immediate attention. Assessing and managing potential cardiac issues take priority over other concerns like needing an IV for surgery, pain control post-hysterectomy, or assistance with mobility. While all clients require care, addressing the chest pain promptly is crucial to ensure the client's safety and well-being.

2. The client with obsessive-compulsive disorder (OCD) is asking for help with the repetitive behaviors. The nurse knows that these are a method of dealing with:

• A. Fearful situations
• B. Depression
• C. Delusions
• D. Anxiety

Correct answer: D

Rationale: The correct answer is D: Anxiety. Repetitive behaviors in OCD serve as a way for individuals to cope with their anxiety. These behaviors are often performed to reduce the distress caused by obsessive thoughts. Choice A, fearful situations, is incorrect because the behaviors are more related to managing anxiety rather than fear itself. Choice B, depression, is incorrect as OCD behaviors are not typically a method of coping with depression. Choice C, delusions, is also incorrect as these behaviors are not aimed at managing delusional thoughts but rather anxiety in OCD.

3. The nurse is teaching a community health class for cancer prevention and screening. Which individual has the highest risk for colon cancer?

• A. Client with irritable bowel syndrome
• B. Family history of colon polyps
• C. Client with cirrhosis of the liver
• D. History of colon surgery

Correct answer: B

Rationale: A family history of colon polyps and/or colon cancer is a significant risk factor for developing colon cancer. Individuals with a family history are more likely to develop colon cancer due to genetic predisposition. While other factors like irritable bowel syndrome, cirrhosis of the liver, and history of colon surgery may contribute to an increased risk of colon cancer, having a family history of colon polyps is the highest risk factor. Irritable bowel syndrome does not directly increase the risk of colon cancer. Cirrhosis of the liver is associated with liver cancer rather than colon cancer. A history of colon surgery may reduce the risk of colon cancer in some cases by removing precancerous polyps.

4. Which electrolyte imbalance would be the nurse's priority concern in the burn client?

• A. Hypernatremia
• B. Hyperkalemia
• C. Hypoalbuminemia
• D. Hypermagnesemia

Correct answer: B

Rationale: The correct answer is hyperkalemia. In a burn client, the nurse's priority concern is hyperkalemia due to cell lysis, which releases potassium into the bloodstream. This can lead to dangerous levels of potassium in the blood. Hypernatremia (Choice A) is less likely in burn clients. Hypoalbuminemia (Choice C) can occur but is not the priority in the immediate management of a burn client. Hypermagnesemia (Choice D) is not typically associated with burn injuries.

5. When caring for a client with a possible diagnosis of placenta previa, which of the following admission procedures should the nurse omit?

• A. perineal shave
• B. enema
• C. urine specimen collection
• D. blood specimen collection

Correct answer: B

Rationale: The correct answer is 'enema.' Administering an enema to a client with placenta previa can dislodge the placenta, leading to an increased risk of bleeding and complications. It is crucial to avoid any interventions that may disrupt the placenta's positioning. Collecting urine and blood specimens are necessary for diagnostic purposes and monitoring, while a perineal shave is a routine procedure that does not pose a risk to the client with placenta previa.

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