Nursing Elites

1. What is the first step in using an automated external defibrillator (AED) on a patient who has collapsed?

• A. Apply the pads to the chest
• B. Turn on the AED and follow the voice prompts
• C. Check the patient's pulse
• D. Ensure the area is clear before delivering a shock

Correct answer: B

Rationale: The correct answer is B: Turn on the AED and follow the voice prompts. This is the first step in using an AED as the device will guide you through the process of analyzing the heart rhythm and delivering a shock if necessary. Choice A, applying the pads to the chest, comes after turning on the AED. Checking the patient's pulse (Choice C) is not necessary before using an AED as the device is specifically designed to assess the need for defibrillation. Ensuring the area is clear (Choice D) is important for safety but is not the initial step in using an AED.

2. What is the correct order of steps in the nursing process?

• A. Assessment, Diagnosis, Planning, Implementation, Evaluation
• B. Planning, Implementation, Evaluation, Diagnosis, Assessment
• C. Diagnosis, Assessment, Planning, Implementation, Evaluation
• D. Implementation, Planning, Evaluation, Diagnosis, Assessment

Correct answer: A

Rationale: The correct order in the nursing process is Assessment, Diagnosis, Planning, Implementation, and Evaluation. Assessment involves gathering information about the patient, Diagnosis is identifying the problem, Planning involves setting goals and outcomes, Implementation is carrying out the plan, and Evaluation is assessing the outcomes. Choices B, C, and D have the steps in the incorrect order, not following the standard nursing process framework. Therefore, the correct answer is option A.

3. What is the most common sign of a localized infection?

• A. Fever
• B. Elevated white blood cell count
• C. Redness, warmth, and swelling at the site of infection
• D. Chills and shivering

Correct answer: C

Rationale: The correct answer is C: Redness, warmth, and swelling at the site of infection. These signs are typical indications of a localized infection, representing inflammation and the body's immune response to the pathogen. Fever (choice A) is a systemic response and not specific to a localized infection. Elevated white blood cell count (choice B) can be seen in both localized and systemic infections. Chills and shivering (choice D) are more related to the body's response to fever and not specifically indicative of a localized infection.

4. Inspiratory and expiratory stridor may be heard in a client who:

• A. Is experiencing an exacerbation of goiter
• B. Is experiencing an acute asthmatic attack
• C. Has aspirated a piece of meat
• D. Has severe laryngotracheitis

Correct answer: D

Rationale: Inspiratory and expiratory stridor are high-pitched, wheezing sounds caused by disrupted airflow due to airway obstruction. Severe laryngotracheitis, involving inflammation and swelling of the larynx and trachea, leads to airway obstruction and can produce both inspiratory and expiratory stridor. Exacerbation of goiter, an acute asthmatic attack, and aspiration of a piece of meat are not typically associated with both inspiratory and expiratory stridor. Therefore, choices A, B, and C are incorrect.

5. A client is recovering from a below-the-knee amputation (BKA). The client reports phantom limb pain. What should the nurse include in the client’s care plan to manage this type of pain?

• A. Apply heat to the residual limb.
• B. Administer prescribed analgesics.
• C. Elevate the residual limb.
• D. Perform range-of-motion exercises.

Correct answer: B

Rationale: Phantom limb pain is a type of pain that feels like it's coming from a body part that's no longer there. It is essential to understand that phantom limb pain is real and should be managed appropriately. Administering prescribed analgesics is the most effective way to address this discomfort. Applying heat, elevating the residual limb, and performing range-of-motion exercises are not effective in managing phantom limb pain since the pain originates from the brain expecting sensory input from the missing limb, rather than being related to physical factors that heat, elevation, or exercises can address.

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