Nursing Elites

1. A healthcare professional in an emergency department is assessing a newly admitted client who is experiencing drooling and hoarseness following a burn injury. Which of the following actions should the healthcare professional take first?

• A. Obtain a baseline ECG.
• B. Obtain a blood specimen for ABG analysis.
• C. Insert an 18-gauge IV catheter.
• D. Administer 100% humidified oxygen.

Correct answer: D

Rationale: In a client experiencing drooling and hoarseness following a burn injury, airway compromise is a critical concern. Administering 100% humidified oxygen is the priority to ensure adequate oxygenation. This intervention takes precedence over obtaining baseline ECG, obtaining blood specimens, or inserting an IV catheter, as airway management and oxygenation are fundamental in the initial assessment and management of a client with potential airway compromise.

2. What is the transparent membrane that focuses the light entering the eyes onto the retina?

• A. Lens
• B. Sclera
• C. Cornea
• D. Pupils

Correct answer: A

Rationale: The correct answer is the lens. The lens is a transparent structure in the eye that helps to focus light onto the retina, which is essential for clear vision. The cornea and sclera are also important parts of the eye, but the lens specifically plays a crucial role in focusing light onto the retina. The sclera is the white outer layer of the eye that helps maintain the shape of the eye, while the cornea is the clear outer covering of the eye that helps to refract light into the eye.

3. The healthcare professional is preparing to take vital signs in an alert client admitted to the hospital with dehydration secondary to vomiting and diarrhea. What is the best method used to assess the client’s temperature?

• A. Oral
• B. Axillary
• C. Radial
• D. Heat-sensitive tape

Correct answer: A

Rationale: The most accurate method for assessing temperature in an alert client is the oral method. It provides a more reliable reflection of the body's core temperature compared to axillary or radial methods. In cases of dehydration, it is important to get an accurate temperature reading to monitor the client's condition closely. Axillary temperature may be affected by environmental factors, while radial temperature measurement is not a standard method for assessing core body temperature. Heat-sensitive tape is not a recognized method for assessing body temperature in clinical practice.

4. A healthcare professional is assessing a client following a gunshot wound to the chest. For which of the following findings should the healthcare professional not monitor to detect a pneumothorax?

• A. Tachypnea
• B. Deviation of the trachea
• C. Bradycardia
• D. Pleuritic pain

Correct answer: C

Rationale: Bradycardia, which is a slow heart rate, is not typically associated with a pneumothorax. In a pneumothorax, the presence of air in the pleural space can lead to lung collapse, causing symptoms such as tachypnea (rapid breathing), deviation of the trachea, and pleuritic pain. Monitoring for bradycardia may not be as relevant in this context as it is not a typical indicator of a pneumothorax.

5. The nurse observes that Mr. Adams begins to have increased difficulty breathing. She elevates the head of the bed to the high Fowler position, which decreases his respiratory distress. The nurse documents this breathing as:

• A. Tachypnea
• B. Eupnea
• C. Orthopnea
• D. Hyperventilation

Correct answer: C

Rationale: Orthopnea is a condition where a person experiences difficulty breathing when lying flat but finds relief when sitting up or standing. Elevating the head of the bed to the high Fowler position helps alleviate this symptom. Tachypnea refers to rapid breathing, eupnea is normal breathing, and hyperventilation is breathing excessively fast or deep.

Similar Questions