Nursing Elites

1. Mr. L was working in his garage at home and had an accident with a power saw. He is brought into the emergency department by a neighbor with a traumatic hand amputation. What is the first action of the nurse?

• A. Place a tourniquet at the level of the elbow
• B. Apply direct pressure to the injury
• C. Administer a bolus of 0.9% Normal Saline
• D. Elevate the injured extremity on a pillow

Correct answer: B

Rationale: The correct first action for the nurse in this scenario is to apply direct pressure to the injury. When a client presents with traumatic hand amputation causing excessive bleeding, the immediate goal is to control the bleeding. Applying direct pressure with a sterile dressing helps to stem the flow of blood and stabilize the patient. Placing a tourniquet at the level of the elbow should be avoided initially as it may lead to further complications such as tissue damage. Administering a bolus of 0.9% Normal Saline is not the priority in this situation where hemorrhage control is crucial. Elevating the injured extremity on a pillow does not address the primary concern of controlling the bleeding and stabilizing the patient.

2. In a 24-year-old woman, the term used to define uterine bleeding in which there is no menstruation is:

• A. Oligomenorrhea
• B. Amenorrhea
• C. Menorrhagia
• D. Metrorrhagia

Correct answer: B

Rationale: Amenorrhea is the correct term for the absence of menstrual periods in a woman of childbearing age. It is typically defined as no menstruation for at least three consecutive cycles or six months. Oligomenorrhea refers to infrequent or irregular menstrual periods rather than complete absence. Menorrhagia is characterized by excessive menstrual bleeding, not the absence of menstruation. Metrorrhagia involves irregular, acyclic bleeding between menstrual periods, which is different from the absence of menstruation.

3. A thirty-five-year-old male has been an insulin-dependent diabetic for five years and now is unable to urinate. Which of the following would you most likely suspect?

• A. Atherosclerosis
• B. Diabetic nephropathy
• C. Autonomic neuropathy
• D. Somatic neuropathy

Correct answer: C

Rationale: In this case, the correct answer is autonomic neuropathy. Autonomic neuropathy affects the autonomic nerves, which control various bodily functions including the bladder. In diabetes, it can lead to bladder paralysis, resulting in symptoms like urgency to urinate and difficulty initiating urination. Atherosclerosis (choice A) is a condition involving the hardening and narrowing of arteries, not directly related to the inability to urinate in this context. Diabetic nephropathy (choice B) primarily affects the kidneys, leading to kidney damage, but does not typically cause urinary retention. Somatic neuropathy (choice D) involves damage to sensory nerves, not the autonomic nerves responsible for bladder control, making it less likely to be the cause of the urinary issue described in the question.

4. A 38-year-old patient with cirrhosis has ascites and 4+ edema of the feet and legs. Which nursing action will be included in the plan of care?

• A. Restrict daily dietary protein intake.
• B. Reposition the patient every 4 hours.
• C. Place the patient on a pressure-relieving mattress.
• D. Perform passive range of motion daily.

Correct answer: C

Rationale: Placing the patient on a pressure-relieving mattress is crucial to decrease the risk of skin breakdown, especially with significant edema and ascites. Adequate dietary protein intake is essential in patients with ascites to improve oncotic pressure and prevent malnutrition. Repositioning the patient every 4 hours alone may not be sufficient to prevent skin breakdown, especially in areas prone to pressure ulcers. Performing passive range of motion exercises is important for maintaining joint mobility but does not directly address the risk of skin breakdown associated with prolonged pressure on vulnerable areas.

5. What nursing action demonstrates the nurse understands the priority nursing diagnosis when caring for patients being treated with splints, casts, or traction?

• A. The nurse assesses extremity pulse, temperature, color, pain, and feeling every hour.
• B. The nurse orders meals with adequate protein and calcium for the patient.
• C. The nurse teaches the patient never to insert objects under a cast to scratch an itch.
• D. The nurse administers oral painkillers as ordered.

Correct answer: A

Rationale: The correct answer is to assess extremity pulse, temperature, color, pain, and feeling every hour. This action aligns with the priority nursing diagnosis of Risk for Peripheral Neurovascular Dysfunction related to fractures. Monitoring these factors is crucial to detect any signs of compromised circulation or nerve function promptly. Option B is incorrect as it does not directly address the priority nursing diagnosis. Option C is important but does not directly relate to the neurovascular aspect. Option D, administering painkillers, is necessary but does not specifically address the priority nursing diagnosis of neurovascular dysfunction.

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