Nursing Elites

1. A client with an electrical burn on the forearm asks the nurse why there is no feeling of pain from the burn. During the dressing change, the nurse determines that the burn is dry, waxy, and white. What information should the nurse provide this client?

• A. The depth of tissue destruction is minor
• B. Pain is interrupted due to nerve compression
• C. The full thickness burn has destroyed the nerves
• D. Second-degree burns are not usually painful

Correct answer: C

Rationale: The correct answer is C: 'The full thickness burn has destroyed the nerves.' In full thickness burns, also known as third-degree burns, the nerve endings are destroyed, leading to a lack of pain sensation at the site of the burn. The description of the burn as dry, waxy, and white indicates a full thickness burn. Choices A, B, and D are incorrect because they do not explain the absence of pain in full thickness burns. Choice A is incorrect as a full-thickness burn involves significant tissue destruction. Choice B is incorrect because nerve compression would not explain the lack of pain in this context. Choice D is incorrect because second-degree burns, unlike full-thickness burns, are painful due to nerve endings being intact.

2. A primigravida at term comes to the prenatal clinic and tells the nurse that she is having contractions every 5 min. The nurse monitors the client for one hour, using an external fetal monitor, and determines that the client’s contractions are 7 to 15 minutes apart, lasting 20 to 30 seconds, with mild intensity by palpation. What action should the nurse take?

• A. Tell the client to go directly to the hospital for admission to labor and delivery for active labor
• B. Send the client home and instruct her to call the clinic when her contractions occur 5 minutes apart for one hour
• C. Tell the client to check into the hospital within the next hour for evaluation of possible urinary tract infection
• D. Advise the client to rest and hydrate, then return if contractions become more regular

Correct answer: B

Rationale: The client should be instructed to call when contractions are 5 minutes apart for an hour to ensure she is in active labor before going to the hospital.

3. The nurse preceptor is orienting a new graduate nurse to the critical care unit. The preceptor asks the new graduate to state symptoms that most likely indicate the beginning of a shock state in a critically ill client. What findings should the new graduate nurse identify?

• A. Tachycardia, mental status change, and low urine output
• B. Warm skin, hypertension, and constricted pupils
• C. Bradycardia, hypotension, and respiratory acidosis
• D. Mottled skin, tachypnea, and hyperactive bowel sounds

Correct answer: A

Rationale: The correct answer is A: Tachycardia, mental status change, and low urine output are early signs of shock. Tachycardia is the body's compensatory mechanism to maintain perfusion, mental status changes can indicate decreased cerebral perfusion, and low urine output reflects poor renal perfusion. Choices B, C, and D are incorrect. Warm skin, hypertension, and constricted pupils are not typical findings in the early stages of shock. Bradycardia, hypotension, and respiratory acidosis are more indicative of late-stage shock. Mottled skin, tachypnea, and hyperactive bowel sounds can be seen in various conditions but are not specific early signs of shock.

4. An 18-year-old gravida 1, at 41-weeks gestation, is undergoing an oxytocin (Pitocin) induction and has an epidural catheter in place for pain control. With each of the last three contractions, the nurse notes a late deceleration. The client is repositioned and oxygen provided, but the late decelerations continue to occur with each contraction. What action should the nurse take first?

• A. Prepare for immediate cesarean birth
• B. Turn off the oxytocin (Pitocin) infusion
• C. Notify the anesthesiologist that the epidural infusion needs to be disconnected
• D. Apply an internal fetal monitoring device and continue to monitor carefully

Correct answer: B

Rationale: In the scenario described, the presence of late decelerations during contractions indicates fetal compromise. To address this, the nurse's initial action should be to turn off the oxytocin (Pitocin) infusion. Oxytocin can contribute to uteroplacental insufficiency, leading to late decelerations. This intervention aims to improve fetal oxygenation and prevent further stress on the fetus. Immediate cesarean birth is not the first-line action unless other interventions fail. Notifying the anesthesiologist about disconnecting the epidural infusion is not the priority in this situation. Applying an internal fetal monitoring device is invasive and not the immediate step needed when late decelerations are present.

5. In attempting to develop a therapeutic relationship with a male adult client transferred to a psychiatric facility after being treated for a self-inflicted gunshot wound, which information is most important for the nurse to determine?

• A. The family's reaction to this situation
• B. The nurse's feelings about this client
• C. What losses the client recently experienced
• D. Why the client attempted to kill himself

Correct answer: C

Rationale: Understanding what losses the client recently experienced is crucial for the nurse in developing a therapeutic relationship. This information helps the nurse comprehend the client's emotional state, the potential triggers for the self-harm behavior, and provides insights into the client's current psychological and social challenges. Choice A, the family's reaction, may be important but is secondary to understanding the client's own experiences. Choice B, the nurse's feelings, is not relevant as the focus should be on the client. Choice D, why the client attempted suicide, is important but delving into recent losses can provide a broader context for the client's emotional distress and suicidal behavior.

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