Nursing Elites

1. A 17-year-old adolescent reports flu-like symptoms and is brought to the emergency room. What intervention should the nurse implement first?

• A. Assess the client's temperature.
• B. Place a mask on the client.
• C. Obtain a chest X-ray per protocol.
• D. Determine the client's blood pressure.

Correct answer: B

Rationale: The correct answer is to place a mask on the client. This intervention is crucial in preventing the spread of infections like the flu, especially in a healthcare setting where the risk of transmission is high. Assessing the client's temperature (Choice A) can be important but is not the priority in this situation. Obtaining a chest X-ray (Choice C) and determining the client's blood pressure (Choice D) are not the immediate interventions needed for a 17-year-old reporting flu-like symptoms.

2. A client at 12 weeks gestation is admitted to the antepartum unit with a diagnosis of hyperemesis gravidarum. Which action is most important for the nurse to implement?

• A. Provide emotional support
• B. Monitor daily weight
• C. Encourage small frequent meals
• D. Initiate prescribed intravenous fluids

Correct answer: D

Rationale: Hyperemesis gravidarum, characterized by severe nausea and vomiting, leads to dehydration and electrolyte imbalances. The priority intervention is initiating IV fluids to correct these imbalances. Providing emotional support is important for the client's well-being, but addressing fluid and electrolyte imbalances takes precedence. Monitoring daily weight and encouraging small frequent meals are beneficial interventions but are not the priority when managing hyperemesis gravidarum.

3. A client with a head injury reports severe nausea. What is the nurse's priority action?

• A. Administer anti-nausea medication as prescribed.
• B. Prepare the client for a CT scan.
• C. Elevate the head of the bed and provide an emesis basin.
• D. Notify the healthcare provider immediately.

Correct answer: D

Rationale: Severe nausea in a client with a head injury may be a sign of increased intracranial pressure. The nurse should notify the healthcare provider immediately to ensure timely intervention, as increased pressure can lead to further complications such as brain herniation. Administering anti-nausea medication or preparing for a CT scan may delay necessary treatment for the underlying cause of the nausea, which could be related to the head injury. Elevating the head of the bed and providing an emesis basin may help manage symptoms but should not be the priority over addressing the potential increase in intracranial pressure.

4. A client with a peripherally inserted central catheter (PICC) line has a fever. What client assessment is most important for the nurse to perform?

• A. Inspect the PICC insertion site for signs of infection.
• B. Observe the antecubital fossa for inflammation.
• C. Auscultate lung sounds for signs of respiratory distress.
• D. Check for signs of phlebitis or thrombosis along the catheter site.

Correct answer: B

Rationale: Observing the antecubital fossa for inflammation is crucial in clients with a PICC line and fever. Inflammation at the site can indicate infection or complications related to the PICC line. Auscultating lung sounds (choice C) is important but not the priority in this situation. Checking for phlebitis or thrombosis (choice D) is relevant but does not address the immediate concern of identifying infection or complications at the insertion site. Inspecting the PICC insertion site (choice A) is also important but observing the antecubital fossa provides a more direct assessment of potential issues with the PICC line.

5. A client recently started on warfarin therapy. What laboratory value is most important to monitor for this client?

• A. Platelet count
• B. Prothrombin time (PT)
• C. Creatinine level
• D. Blood urea nitrogen (BUN)

Correct answer: B

Rationale: Prothrombin time (PT) is the most important laboratory value to monitor for clients on warfarin therapy. PT helps determine how long it takes blood to clot and ensures the warfarin dose is within the therapeutic range to prevent either excessive bleeding or clotting. Monitoring platelet count is important for assessing the risk of bleeding, but PT is more specific to warfarin therapy. Creatinine level and BUN are indicators of kidney function and are not directly related to warfarin therapy.

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