Nursing Elites

1. A client is admitted for first and second degree burns on the face, neck, anterior chest, and hands. The nurse's priority should be

• A. Cover the areas with dry sterile dressings
• B. Assess for dyspnea or stridor
• C. Initiate intravenous therapy
• D. Administer pain medication

Correct answer: B

Rationale: The correct answer is to assess for dyspnea or stridor. In burn cases involving the face, neck, or chest, there is a risk of airway compromise due to swelling. Dyspnea (difficulty breathing) or stridor (noisy breathing) can indicate airway obstruction or respiratory distress, which requires immediate intervention. Covering the burns with dry sterile dressings (choice A) can be important but ensuring airway patency takes precedence. Initiating intravenous therapy (choice C) may be necessary but not the priority over assessing the airway. Administering pain medication (choice D) is important for comfort but should come after ensuring the airway is clear and breathing is adequate.

2. A client who is to have antineoplastic chemotherapy tells the nurses of a fear of being sick all the time and wishes to try acupuncture. Which of these beliefs stated by the client would be incorrect about acupuncture?

• A. Some needles go as deep as 3 inches, depending on where they're placed in the body and what the treatment is for. The needles are usually left in for 15 to 30 minutes.
• B. In traditional Chinese medicine, imbalances in the basic energetic flow of life — known as qi or chi — are thought to cause illness.
• C. The flow of life is believed to flow through major pathways in your body rather than nerve clusters.
• D. By inserting extremely fine needles into some of the over 400 acupuncture points in various combinations, it is believed that energy flow will rebalance to allow the body's natural healing mechanisms to take over.

Correct answer: C

Rationale: The belief stated in option C is incorrect about acupuncture. Acupuncture is based on the concept of qi flowing through major pathways in the body, known as meridians, rather than nerve clusters. This traditional Chinese medicine practice aims to balance the flow of qi to promote health and healing. Options A, B, and D are consistent with the principles of acupuncture and are not incorrect beliefs. Option A describes the depth and duration of needle placement, option B explains the role of imbalances in qi flow causing illness, and option D outlines how acupuncture helps rebalance energy flow for the body's natural healing mechanisms.

3. Discharge instructions for a client taking alprazolam (Xanax) should include which of the following?

• A. Sedative hypnotics are effective analgesics
• B. Sudden cessation of alprazolam (Xanax) can cause rebound insomnia and nightmares
• C. Caffeine beverages can increase the effect of sedative hypnotics
• D. Avoidance of excessive exercise and high temperature is recommended

Correct answer: B

Rationale: The correct answer is B. Alprazolam should not be stopped abruptly as it can cause rebound insomnia and nightmares; gradual tapering is necessary. Choice A is incorrect as sedative hypnotics are not primarily used as analgesics. Choice C is incorrect as caffeine can decrease the effects of sedative hypnotics rather than increase them. Choice D is incorrect as there is no specific recommendation to avoid excessive exercise or high temperature related to alprazolam use.

4. A client is receiving intravenous antibiotics for the treatment of a severe infection. Which of these assessments is a priority for the nurse to perform?

• A. Monitor the client's temperature
• B. Assess the client's pain level
• C. Check the intravenous (IV) site for signs of phlebitis
• D. Monitor the client's respiratory status

Correct answer: C

Rationale: When a client is receiving intravenous antibiotics, checking the IV site for signs of phlebitis is a priority assessment for the nurse. Phlebitis is an inflammation of the vein, which can lead to serious complications such as infection and thrombosis. Monitoring the IV site helps prevent these complications and ensures the safe delivery of antibiotics. While monitoring the client's temperature, pain level, and respiratory status are important assessments, they are not the priority in this scenario where IV antibiotic administration requires close monitoring for complications like phlebitis.

5. The nurse is planning care for a client with a CVA. Which of the following measures planned by the nurse would be most effective in preventing skin breakdown?

• A. Place the client in the wheelchair for four hours each day
• B. Pad the bony prominences
• C. Reposition every two hours
• D. Massage reddened bony prominence

Correct answer: C

Rationale: Repositioning every two hours is the most effective measure in preventing skin breakdown for a client with a CVA. This practice helps to relieve pressure on the skin, reducing the risk of pressure ulcers. Placing the client in a wheelchair for extended periods (Choice A) can increase pressure on specific areas, leading to skin breakdown. Padding bony prominences (Choice B) can provide some protection but may not address the root cause of pressure ulcers. Massaging reddened bony prominences (Choice D) can potentially worsen the condition by causing further damage to already compromised skin.

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