Nursing Elites

1. The nurse is teaching basic cardiopulmonary resuscitation (CPR) to individuals in the community. What is the correct order of basic CPR steps?

• A. Ensure the scene is safe, assess responsiveness, call for help, begin chest compressions, give two rescue breaths
• B. Give two rescue breaths
• C. Look, listen, and feel for breathing
• D. Begin chest compressions

Correct answer: A

Rationale: The correct order of basic CPR steps is as follows: first, ensure the scene is safe to approach, then assess the individual's responsiveness. After confirming the need for help, start chest compressions, then provide two rescue breaths. Option B, 'Give two rescue breaths,' is incorrect as chest compressions should be initiated before giving rescue breaths. Option C, 'Look, listen, and feel for breathing,' is also incorrect as immediate chest compressions are crucial in CPR. Option D, 'Begin chest compressions,' is partially correct but misses the crucial initial steps of ensuring scene safety and assessing responsiveness.

2. What type of diet is recommended for patients with diverticulitis during an acute flare-up?

• A. High-fiber
• B. Low-residue
• C. Low-fat
• D. High-protein

Correct answer: B

Rationale: During an acute flare-up of diverticulitis, a low-residue diet is recommended. This diet helps reduce bowel movements and minimize irritation to the digestive tract, allowing the inflamed diverticula to heal. High-fiber foods are usually avoided during flare-ups as they can exacerbate symptoms. Low-fat and high-protein diets are not specifically recommended for diverticulitis flare-ups. Therefore, option B is the correct choice.

3. The nurse is caring for the client recovering from intestinal surgery. Which assessment finding would require immediate intervention?

• A. Presence of thin pink drainage in the Jackson Pratt
• B. Guarding when the nurse touches the abdomen
• C. Tenderness around the surgical site during palpation
• D. Complaints of chills and feeling feverish

Correct answer: D

Rationale: Complaints of chills and feeling feverish may indicate infection, which requires immediate intervention. This finding suggests a systemic response to infection, which can be life-threatening if not promptly addressed. Options A, B, and C are common postoperative findings and may not necessarily require immediate intervention unless accompanied by other concerning signs or symptoms.

4. The nurse is preparing the plan of care for a client with fluid volume deficit. Which interventions should the nurse include in the plan of care?

• A. Monitor vital signs every two (2) hours until stable
• B. Weigh the client in the same clothing at the same time daily
• C. Administer mouth care every eight (8) hours
• D. A, B, and C

Correct answer: D

Rationale: The correct interventions for a client with fluid volume deficit include monitoring vital signs every two hours until stable, weighing the client in the same clothing at the same time daily, and assessing skin turgor. Monitoring vital signs helps in early detection of changes, daily weighing can indicate fluid retention or loss, and skin turgor assessment is a reliable indicator of hydration status. Administering mouth care every eight hours is not directly related to managing fluid volume deficit and should not be included in the plan of care for this specific condition.

5. A client is transferred from the emergency department to the locked psychiatric unit after attempting suicide by taking 200 acetaminophen (Tylenol) tablets. The client is now awake and alert but refuses to speak with the nurse. In this situation, the nurse’s first priority is to:

• A. Establish a rapport to foster trust
• B. Place the client in full restraints
• C. Try to communicate with the client in writing
• D. Ensure safety by initiating suicide precautions

Correct answer: D

Rationale: In this scenario, the nurse's highest priority should be to ensure the client's safety by initiating suicide precautions. Given the history of a suicide attempt by taking a large number of acetaminophen tablets, there is a high risk of further self-harm. Placing the client in full restraints without assessing the situation properly may escalate anxiety and hinder therapeutic communication. Trying to communicate with the client in writing could be an option but ensuring immediate safety takes precedence. Establishing rapport is essential for building trust and therapeutic relationship, but safety concerns must be addressed first in this critical situation.

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