Nursing Elites

1. When caring for a client diagnosed with delirium, what condition should the nurse prioritize investigating?

• A. Investigate medication history
• B. Investigate sensory deficits
• C. Investigate cognitive functioning
• D. Investigate for signs of infection

Correct answer: D

Rationale: The correct answer is to investigate for signs of infection when caring for a client diagnosed with delirium. Infections can frequently cause or worsen delirium. While investigating medication history, sensory deficits, and cognitive functioning may be important in the overall care of the client, when prioritizing, the nurse should first rule out or address potential infections due to their significant impact on delirium.

2. What are the signs and symptoms of a pulmonary embolism?

• A. Sudden shortness of breath
• B. Chest pain
• C. Cough with blood
• D. All of the above

Correct answer: D

Rationale: A pulmonary embolism can manifest with sudden shortness of breath, chest pain, and coughing up blood. These symptoms are classic presentations of a pulmonary embolism due to the blockage of blood flow to the lungs. Therefore, the correct answer is 'All of the above.' Each symptom alone can be seen in various other conditions, but when occurring together, they strongly suggest a pulmonary embolism. Sudden shortness of breath is due to decreased oxygenation, chest pain can result from the strain on the heart, and coughing with blood may indicate damage to the lung tissue. Choosing any single symptom would not encompass the full range of presentations seen in a pulmonary embolism.

3. A nurse is preparing to administer a rectal suppository to a school-age child. Which of the following actions should the nurse plan to take?

• A. Insert the suppository 1 cm into the rectum
• B. Insert the suppository 2 cm into the rectum
• C. Insert the suppository past the anal sphincters
• D. Insert the suppository using two fingers

Correct answer: C

Rationale: The correct answer is C: 'Insert the suppository past the anal sphincters.' When administering a rectal suppository, it is essential to insert it past the anal sphincters to ensure proper placement and absorption. Choices A and B are incorrect because the suppository should be inserted further than just 1 or 2 cm into the rectum to reach the optimal absorption site. Choice D is incorrect as using two fingers is not necessary and may cause discomfort to the child.

4. A nurse is reinforcing teaching about wound care for a client who has a wound requiring irrigation. What is an important instruction?

• A. Wear sterile gloves when applying a new dressing
• B. Cleanse the wound from the center outwards
• C. Keep the wound dry between dressing changes
• D. Apply an antimicrobial ointment to the wound

Correct answer: B

Rationale: The correct answer is to cleanse the wound from the center outwards. This technique helps reduce the risk of contamination by pushing debris away from the wound. Option A, wearing sterile gloves, is important for infection control but not specifically related to wound irrigation. Option C, keeping the wound dry, is not suitable for wound irrigation, which often involves using solutions to clean the wound. Option D, applying an antimicrobial ointment, is not typically done during wound irrigation as the focus is on cleansing the wound.

5. A healthcare provider is assessing a client who has received a preoperative dose of morphine. Which of the following findings is the priority to report to the provider?

• A. Client reports nausea.
• B. Urinary output of 20 mL/hr.
• C. Oxygen saturation 90%.
• D. Respiratory rate 14/min.

Correct answer: C

Rationale: An oxygen saturation of 90% is below the expected reference range and could indicate respiratory depression, a serious side effect of morphine. This finding requires immediate attention as it may lead to hypoxia. Nausea (choice A) is a common side effect of morphine but does not pose an immediate threat. A urinary output of 20 mL/hr (choice B) may indicate decreased renal perfusion but is not as critical as respiratory compromise. A respiratory rate of 14/min (choice D) is within the normal range and does not suggest immediate danger.

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