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 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 appropriate as it demonstrates cultural sensitivity. Ginger is commonly used to alleviate nausea, particularly in Asian cultures. Contacting the physician to discuss the use of ginger ensures the client's safety and respects their preferences. Choices B and C are incorrect as they disregard the client's request and fail to acknowledge their cultural beliefs. Choice D is incorrect because it does not address the client's desire to use ginger for relief.

3. Which of the following observations is most important when assessing a client's breathing?

• A. presence of breathing and pulse rate
• B. breathing pattern and adequacy of breathing
• C. presence of breathing and adequacy of breathing
• D. patient position and adequacy of breathing

Correct answer: C

Rationale: The correct answer is the presence of breathing and adequacy of breathing. It is crucial not only to confirm that the client is breathing but also to ensure that the breathing is adequate for proper oxygenation. Choices A, B, and D are incorrect because while pulse rate, breathing pattern, and patient position are relevant aspects to consider, the most critical observations in assessing a client's breathing are the presence and adequacy of breathing.

4. A healthcare provider is caring for a patient who has experienced burns to the right lower extremity. According to the Rule of Nines, which of the following percentages most accurately describes the severity of the injury?

• A. 36%
• B. 27%
• C. 18%
• D. 9%

Correct answer: C

Rationale: According to the Rule of Nines, the right lower extremity accounts for 18% of the total body surface area. The Rule of Nines divides the body into regions, each representing 9% or a multiple of 9%, allowing for a quick estimation of the extent of burns. In this case, the correct answer is 18% as it corresponds to the percentage allocated for each lower extremity. Choices A, B, and D are incorrect as they do not match the standard allocation for the right lower extremity in the Rule of Nines.

5. A client, age 28, was recently diagnosed with Hodgkin's disease. After staging, therapy is planned to include combination radiation therapy and systemic chemotherapy with MOPP"?nitrogen mustard, vincristine (Onconvin), prednisone, and procarbazine. In planning care for this client, the nurse should anticipate which of the following side effects to contribute to a sense of altered body image?

• A. Cushingoid appearance
• B. Alopecia
• C. Temporary or permanent sterility
• D. Pathologic fractures

Correct answer: B

Rationale: The correct answer is B: Alopecia. Chemotherapy drugs like vincristine can cause alopecia, which is hair loss. This side effect can significantly impact a patient's body image. While Cushingoid appearance (A) can be a side effect of long-term steroid use, temporary or permanent sterility (C) may affect a patient's future fertility but not necessarily alter body image. Pathologic fractures (D) are not common side effects of Hodgkin's disease or its treatment and do not directly contribute to a sense of altered body image in the same way as alopecia does.

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