Nursing Elites

1. To differentiate adventitious lung sounds associated with heart failure from those associated with bacterial pneumonia, what information should the nurse review?

• A. Sputum culture findings
• B. Oxygen saturation level
• C. Amount of coughing
• D. Respiratory rate

Correct answer: A

Rationale: The correct answer is A: Sputum culture findings. Reviewing sputum culture findings can provide valuable information to differentiate between bacterial pneumonia and heart failure, as the type of bacteria present in the sputum can help identify the specific infection. Oxygen saturation level (Choice B) is important for assessing oxygenation status but does not directly help in distinguishing between the two conditions based on lung sounds. The amount of coughing (Choice C) and respiratory rate (Choice D) may offer some clinical insights but are not as specific or diagnostic as sputum culture findings when differentiating between heart failure and bacterial pneumonia.

2. A young adult who is hit with a baseball bat on the temporal area of the left skull is conscious when admitted to the ED and is transferred to the Neurological Unit to be monitored for signs of closed head injury. Which assessment finding is indicative of a developing epidural hematoma?

• A. Altered consciousness within the first 24 hours after injury
• B. Confusion immediately following the injury
• C. Headache that resolves quickly
• D. Brief loss of consciousness with a lucid interval

Correct answer: A

Rationale: The correct answer is A. Epidural hematoma often presents with a brief loss of consciousness followed by a lucid interval and then a rapid decline in consciousness. Therefore, altered consciousness within the first 24 hours after the injury is indicative of a developing epidural hematoma. Choices B, C, and D are incorrect because confusion immediately following the injury, headache that resolves quickly, and brief loss of consciousness with a lucid interval are not specific signs of epidural hematoma.

3. When the client asks the nurse if they have ever been with someone when they died, what is the nurse’s best response?

• A. “Yes, I have. Do you have some questions about dying?”
• B. “Several times. Now, let’s get your dressing changed.”
• C. “A few times. It was peaceful and there was no pain.”
• D. “Yes, but you’re doing great. Are you concerned about dying?”

Correct answer: A

Rationale: Choice A is the best response as it acknowledges the client's question and opens the door for further discussion about dying if the client wishes to. It shows empathy and encourages the client to express any concerns they may have. Choices B and C do not directly address the client's question or offer an opportunity for him to explore his concerns. Choice D acknowledges the experience but fails to address the client's question directly and does not encourage further discussion.

4. The nurse is teaching a male adolescent recently diagnosed with type 1 diabetes mellitus (DM) about self-injecting insulin. Which approach is best for the nurse to use to evaluate the effectiveness of the teaching?

• A. Observe him demonstrating the self-injection technique to another diabetic adolescent.
• B. Ask the adolescent to describe his comfort level with injecting himself with insulin.
• C. Review his glycosylated hemoglobin level 3 months after the teaching session.
• D. Have the adolescent list the steps for safe insulin administration.

Correct answer: C

Rationale: Reviewing the glycosylated hemoglobin level after a few months is the best approach to evaluate the effectiveness of teaching self-injection. This measurement provides an objective indicator of the adolescent's glucose control over time, reflecting the impact of insulin self-administration education. Choices A, B, and D do not directly assess the long-term impact of the teaching on the adolescent's diabetes management.

5. A client with eczema is experiencing severe pruritus. Which PRN prescription should the nurse administer?

• A. Topical corticosteroid
• B. Topical scabicide
• C. Topical alcohol rub
• D. Transdermal analgesic

Correct answer: A

Rationale: The correct answer is A: Topical corticosteroid. Topical corticosteroids are commonly used to manage itching in eczema by reducing inflammation and suppressing the immune response. In this case, for severe pruritus in eczema, a topical corticosteroid would be appropriate. Choice B, Topical scabicide, is used to treat scabies, not eczema. Choice C, Topical alcohol rub, is not typically used to manage pruritus in eczema. Choice D, Transdermal analgesic, is more for pain relief and not specifically targeted at managing itching associated with eczema.

Similar Questions