Nursing Elites

1. A client is admitted with a severe burn injury. What is the nurse's priority intervention?

• A. Monitor the client's urine output.
• B. Administer intravenous fluids.
• C. Apply cool, moist compresses to the burn area.
• D. Cover the burn area with a sterile dressing.

Correct answer: B

Rationale: The correct answer is B: Administer intravenous fluids. In a client with severe burn injury, the priority intervention is to administer intravenous fluids to prevent shock. Monitoring urine output (Choice A) is important but not the priority. Applying cool, moist compresses (Choice C) can be beneficial but is not the priority over fluid resuscitation. Covering the burn area with a sterile dressing (Choice D) is important for wound care but is not the immediate priority in managing severe burns.

2. A nurse is caring for a client with a chest tube following lung surgery. What is the most important intervention to ensure the chest tube functions properly?

• A. Clamp the tube if there is excessive drainage
• B. Empty the drainage chamber every 2 hours
• C. Keep the drainage system below chest level
• D. Milk the tube to prevent clots from forming

Correct answer: C

Rationale: The correct answer is C. Keeping the chest tube drainage system below chest level ensures that gravity assists with drainage and prevents fluid or air from flowing back into the pleural space, which could compromise lung function. Clamping the tube if there is excessive drainage (choice A) is incorrect as it can lead to a buildup of pressure and compromise the drainage system. Emptying the drainage chamber every 2 hours (choice B) is important but not as crucial as maintaining the drainage system below chest level. Milking the tube to prevent clots from forming (choice D) is incorrect and could lead to complications such as tube occlusion or damage to the tissue.

3. A client with pneumonia is receiving oxygen therapy. What assessment finding requires immediate intervention?

• A. Increased oxygen saturation of 96%.
• B. Oxygen saturation of 89%.
• C. Respiratory rate of 20 breaths per minute.
• D. Decreased heart rate of 70 beats per minute.

Correct answer: B

Rationale: The correct answer is B. An oxygen saturation of 89% indicates hypoxemia, which is below the normal range (usually 95-100%). This finding requires immediate intervention as it signifies inadequate oxygenation. Options A, C, and D are within normal limits and do not indicate an urgent need for intervention. Option A indicates a good oxygen saturation level, option C denotes a normal respiratory rate, and option D suggests a normal heart rate. Therefore, these options do not require immediate intervention compared to the critically low oxygen saturation level of 89% in option B.

4. The psychiatric nurse is caring for clients in an adolescent unit. Which client requires the nurse's immediate attention?

• A. A 17-year-old client with schizophrenia who is pacing the hallways
• B. An 18-year-old client with antisocial behavior who is being yelled at by other clients
• C. A 16-year-old client with depression who refuses to eat meals
• D. A 15-year-old client with anxiety who is quietly reading in a corner

Correct answer: B

Rationale: The client with antisocial behavior being yelled at by peers may escalate the situation, potentially leading to violence or self-harm. Addressing the situation quickly helps prevent harm and de-escalates the conflict. Choices A, C, and D do not present immediate risks that require urgent intervention compared to the potential danger of a conflict escalating to violence with the client exhibiting antisocial behavior.

5. A client is being discharged following a cystectomy and urinary diversion. What is the most important instruction for the nurse to provide?

• A. Avoid lifting heavy objects for six weeks.
• B. Report any signs of cloudy urine output.
• C. Drink 8 glasses of water a day.
• D. Monitor for signs of infection at the surgical site.

Correct answer: B

Rationale: The most important instruction for the nurse to provide to a client following a cystectomy and urinary diversion is to report any signs of cloudy urine output. Cloudy urine may indicate infection, which is a serious concern in clients with a urinary diversion. Instructing the client to report any signs of infection immediately is crucial to prevent complications. Avoiding heavy lifting is important for postoperative recovery but not as critical as identifying a potential infection. Drinking an adequate amount of water is generally beneficial for health but not the most crucial instruction in this scenario. While monitoring for signs of infection at the surgical site is essential, cloudy urine is a more specific and immediate indicator of a potential problem in clients with urinary diversions.

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