Nursing Elites

1. What is the most important assessment for a patient with suspected pneumonia?

• A. Monitor lung sounds
• B. Check oxygen saturation
• C. Assess for cough
• D. Assess for fever

Correct answer: A

Rationale: The most important assessment for a patient with suspected pneumonia is to monitor lung sounds. Lung sounds provide crucial information about the severity of pneumonia, such as crackles or decreased air entry. This assessment helps in evaluating the effectiveness of ventilation and oxygenation. While checking oxygen saturation is important, monitoring lung sounds gives more direct information about the lung involvement in pneumonia. Assessing for cough and fever are also relevant but do not provide as direct and critical information as monitoring lung sounds in the context of suspected pneumonia.

2. A nurse is caring for a client who is receiving continuous enteral feedings through a nasogastric tube. Which of the following actions should the nurse take?

• A. Keep the head of the bed elevated to 15 degrees.
• B. Change the feeding bag every 48 hours.
• C. Administer the feeding through a large-bore syringe.
• D. Flush the tube with 0.9% sodium chloride every 4 hours.

Correct answer: D

Rationale: The correct action the nurse should take is to flush the tube with 0.9% sodium chloride every 4 hours. This helps maintain patency and prevents clogs during enteral feedings. Keeping the head of the bed elevated to 15 degrees (Choice A) is important for preventing aspiration but is not directly related to tube care. Changing the feeding bag every 48 hours (Choice B) is not a standard practice as the bag should be changed every 24 hours to prevent bacterial growth. Administering the feeding through a large-bore syringe (Choice C) is incorrect as enteral feedings should be given through an appropriate feeding pump for accuracy and safety.

3. A nurse is assessing a client who is postoperative following a total knee arthroplasty. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 90/min
• B. Capillary refill of 2 seconds
• C. Wound drainage of 30 mL in 8 hours
• D. Warmth and redness in the calf

Correct answer: D

Rationale: The correct answer is D. Warmth and redness in the calf are indicative of a possible deep vein thrombosis (DVT), a serious complication post-surgery that requires immediate attention. Reporting this finding promptly to the provider is crucial for timely intervention. Choices A, B, and C are within normal limits for a postoperative client and do not indicate a potentially life-threatening condition like DVT.

4. What is the best way to manage a patient's pain postoperatively?

• A. Administer analgesics regularly
• B. Administer pain medication PRN
• C. Encourage deep breathing exercises
• D. Provide distraction techniques

Correct answer: A

Rationale: The correct answer is A: Administer analgesics regularly. Postoperative pain management often requires a scheduled, around-the-clock administration of analgesics to maintain a consistent level of pain relief and minimize the risk of breakthrough pain. Choice B, administering pain medication PRN (as needed), may lead to inadequate pain control as the medication is not given preemptively. Choice C, encouraging deep breathing exercises, can be beneficial for pain management but should be used as an adjunct to analgesic therapy. Choice D, providing distraction techniques, may help some patients cope with pain but should not be the primary method of pain management postoperatively.

5. In an emergency department following a community disaster, a healthcare provider is performing triage for multiple clients. To which of the following types of injuries should the provider assign the highest priority?

• A. Below-the-knee amputation.
• B. Fractured tibia.
• C. 95% full-thickness body burn.
• D. 10 cm laceration to the forearm.

Correct answer: A

Rationale: During disaster triage, clients with severe injuries that are immediately life-threatening and have a high likelihood of mortality without intervention are assigned the highest priority. A below-the-knee amputation falls into this category as it indicates a critical injury that requires immediate attention to prevent further complications or loss of life. Fractured tibia, a 95% full-thickness body burn, and a 10 cm laceration to the forearm, while serious, do not pose the same level of immediate life-threatening risk as a below-the-knee amputation in the context of disaster triage.

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