Nursing Elites

1. Which client should be seen first by the Emergency Department nurse?

• A. A six-year-old with a femur fracture.
• B. A two-year-old with a fever of 102 degrees F.
• C. A three-year-old with wheezes in the right lower lobe.
• D. A two-year-old whose gastrostomy tube came out.

Correct answer: C

Rationale: The priority in the emergency department is to assess and manage clients based on the severity of their condition. In this scenario, the three-year-old with wheezes in the right lower lobe should be seen first because respiratory distress takes precedence over other conditions. Wheezing indicates potential airway compromise, which requires immediate attention to ensure adequate oxygenation. The other options are important but do not pose an immediate threat to the client's airway and breathing. A femur fracture, fever, or a dislodged gastrostomy tube can be addressed after ensuring the child with respiratory distress is stable.

2. A patient has been diagnosed with diabetes mellitus. Which of the following is not a clinical sign of diabetes mellitus?

• A. Polyphagia
• B. Polyuria
• C. Metabolic acidosis
• D. Lower extremity edema

Correct answer: D

Rationale: Polyphagia, polyuria, and metabolic acidosis are common clinical signs of diabetes mellitus. Polyphagia refers to excessive hunger, polyuria is excessive urination, and metabolic acidosis can occur due to poorly controlled diabetes. Lower extremity edema, on the other hand, is not a typical clinical sign of diabetes mellitus. Edema in the lower extremities is more commonly associated with conditions like heart failure or kidney disease rather than diabetes mellitus.

3. A pregnant Asian client who is experiencing morning sickness wants to take ginger to relieve the nausea. Which of the following responses by the nurse is appropriate?

• A. "I will call your physician to see if we can start some ginger."?
• B. "We don't use home remedies in this clinic."?
• C. "Herbs are not as effective as regular medicines."?
• D. "Just eat some dry crackers instead."?

Correct answer: A

Rationale: The correct response is to offer to consult with the physician regarding the use of ginger, showing cultural sensitivity. Ginger is known to help relieve nausea, especially in pregnancy. Choice A is the correct answer as it respects the client's preference for a home remedy and involves the physician in the decision-making process. Choice B dismisses the client's preference for a home remedy without exploring its potential benefits. Choice C makes a generalized statement discrediting the effectiveness of herbs, which is not evidence-based and disregards the client's beliefs. Choice D offers an alternative without addressing the client's specific request, failing to acknowledge the client's autonomy and cultural background.

4. The client is being discharged after a concussion. Which of the following symptoms should be reported?

• A. Difficulty waking up
• B. Headache (3/10 on the pain scale)
• C. Bruising on knees and elbows
• D. Achy feeling all over

Correct answer: A

Rationale: The correct answer is 'Difficulty waking up' because it indicates a change in consciousness, which is a concerning symptom following a concussion. Reporting this symptom is crucial as it may signify a more severe head injury. 'Headache (3/10 on the pain scale)' may be common after a concussion but is not as urgent as a change in consciousness. 'Bruising on knees and elbows' is likely unrelated to the concussion and not a priority for reporting. 'Achy feeling all over' is a vague symptom and not specific to a concerning change in the client's condition post-concussion.

5. A violation of a patient's confidentiality occurs if two nurses are discussing client information in which of the following scenarios?

• A. With a physical therapist treating the patient
• B. With a social worker planning for discharge
• C. With another nurse on duty to plan for break time
• D. In the hallway outside the patient's room

Correct answer: D

Rationale: The correct answer is 'In the hallway outside the patient's room.' Discussing client information in a public area like a hallway can potentially breach patient confidentiality as it increases the risk of unauthorized individuals overhearing sensitive information. Choices A, B, and C involve discussing client information with other healthcare professionals in appropriate settings, which are more likely to maintain patient confidentiality compared to discussing in a public space like a hallway. Option D is the correct choice because it highlights a scenario where patient information is at higher risk of exposure to unauthorized individuals, hence violating patient confidentiality.

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