Nursing Elites

1. When caring for a client in hemorrhagic shock, how should the nurse position the client?

• A. Flat in bed with legs elevated.
• B. Flat in bed.
• C. Trendelenburg position.
• D. Semi-Fowler's position.

Correct answer: A

Rationale: When caring for a client in hemorrhagic shock, the nurse should position the client flat in bed with legs elevated. Elevating the legs helps increase venous return to the heart, aiding in the management of hemorrhagic shock by maintaining perfusion to vital organs.

2. The healthcare provider is assessing a client with a diagnosis of pneumonia. Which assessment finding is most concerning?

• A. Coarse crackles in the lungs.
• B. Fever of 101.2°F (38.4°C).
• C. Productive cough with yellow sputum.
• D. Respiratory rate of 28 breaths per minute.

Correct answer: D

Rationale: A respiratory rate of 28 breaths per minute (D) is most concerning because it indicates respiratory distress and requires immediate intervention. While coarse crackles (A), fever (B), and productive cough (C) are common findings in pneumonia, a high respiratory rate signifies a more severe condition that needs prompt attention to prevent respiratory failure. Monitoring the respiratory rate is crucial in assessing the severity of respiratory distress in pneumonia, as it can rapidly progress to respiratory failure if not managed promptly.

3. The healthcare professional is using the Glasgow Coma Scale to perform a neurologic assessment. A comatose client winces and pulls away from a painful stimulus. What action should the healthcare professional take next?

• A. Document that the client responds to a painful stimulus.
• B. Observe the client's response to verbal stimulation.
• C. Place the client on seizure precautions for 24 hours.
• D. Report decorticate posturing to the healthcare provider.

Correct answer: A

Rationale: The client's response to a painful stimulus indicates a purposeful reaction, which should be accurately documented as per the assessment findings. This documentation is essential for ongoing monitoring and communication of the client's condition to the healthcare team.

4. What type of technique should the nurse observe when preparing to insert an indwelling catheter?

• A. Clean technique.
• B. Medical Asepsis.
• C. Isolation Protocol.
• D. Sterile Technique.

Correct answer: D

Rationale: When inserting an indwelling catheter, the nurse must observe sterile technique to minimize the risk of infections. Sterile technique involves using sterile equipment and maintaining a sterile field to prevent introducing pathogens into the urinary tract.

5. A male client is on contact precautions due to an infected draining wound and is being discharged home. The client lives at home with his wife and their adolescent daughter. What discharge instruction should the nurse include for the client?

• A. Use disposable plates and utensils.
• B. Stay in a room with the door closed.
• C. Dispose of soiled dressings in plastic bags that are securely closed.
• D. Others who are in the same room with the client should wear a mask.

Correct answer: C

Rationale: When a client is on contact precautions due to an infected draining wound, it is important to prevent contact with wound secretions. Therefore, disposing of soiled dressings in securely closed plastic bags helps contain and prevent the spread of infectious material, reducing the risk of transmission to others in the household.

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