Nursing Elites

1. A nurse in an emergency department is caring for a client who has sustained multiple injuries. The nurse observes the client's thorax moving inward during inspiration and outward during expiration. The nurse should suspect which of the following injuries?

• A. Flail chest
• B. Hemothorax
• C. Pulmonary contusion
• D. Pneumothorax

Correct answer: A

Rationale: The correct answer is A: Flail chest. Flail chest results from multiple rib fractures, causing paradoxical chest movement where the injured part moves inward during inspiration and outward during expiration, interfering with ventilation. Choice B, Hemothorax, involves blood in the pleural cavity and does not typically cause paradoxical chest movement. Choice C, Pulmonary contusion, is a bruise to the lung tissue and does not present with paradoxical chest movement. Choice D, Pneumothorax, is the presence of air in the pleural space, leading to lung collapse, but it does not demonstrate paradoxical chest movement like in flail chest.

2. What teaching should be provided to a patient following cataract surgery?

• A. Avoid NSAIDs
• B. Wear dark glasses outdoors
• C. Creamy white drainage is normal
• D. Avoid alcohol

Correct answer: A

Rationale: The correct teaching to provide to a patient following cataract surgery is to avoid NSAIDs. NSAIDs should be avoided post-cataract surgery to reduce the risk of bleeding. Choice B, wearing dark glasses outdoors, is important to protect the eyes from bright light but is not directly related to medication use. Choice C, stating that creamy white drainage is normal, is incorrect as drainage should be monitored for excessive redness, swelling, or pain. Choice D, avoiding alcohol, is not a direct post-cataract surgery teaching point related to medication use.

3. A nurse in a rural community center is providing education to a group of clients about first aid interventions for snake bites. Which of the following instructions should the nurse include in the teaching?

• A. Apply an ice pack directly to the affected area
• B. Immobilize the affected extremity with a splint
• C. Place a tourniquet above and below the affected area
• D. Elevate the affected extremity

Correct answer: B

Rationale: The correct answer is to immobilize the affected extremity with a splint. This helps to slow the spread of venom by limiting movement. Applying an ice pack directly to the affected area (Choice A) is not recommended for snake bites as it could exacerbate tissue damage. Placing a tourniquet above and below the affected area (Choice C) is also not advised as it can lead to further complications. Elevating the affected extremity (Choice D) is not recommended for snake bites; keeping it below the level of the heart is more appropriate to reduce venom spread.

4. A home health nurse is providing teaching to the family of a client who has a seizure disorder. Which of the following interventions should the nurse include in the teaching?

• A. Keep a padded tongue depressor near the bedside
• B. Place a pillow under the client's head during a seizure
• C. Administer diazepam intravenously at the onset of seizures
• D. Position the client on their side during a seizure

Correct answer: D

Rationale: The correct intervention for a client who has a seizure disorder is to position the client on their side during a seizure. This helps to prevent aspiration and ensures a patent airway. Keeping a padded tongue depressor near the bedside (Choice A) is not recommended as it can cause injury during a seizure. Placing a pillow under the client's head during a seizure (Choice B) is also not advised as it can obstruct the airway. Administering diazepam intravenously at the onset of seizures (Choice C) is not typically done at home without healthcare provider direction.

5. A patient reports abdominal cramping after enema administration. What is the appropriate action?

• A. Lower the height of the solution container
• B. Stop the procedure and remove tubing
• C. Increase the flow of enema solution
• D. Continue the enema at a slower rate

Correct answer: A

Rationale: Lowering the height of the enema solution container is the appropriate action when a patient reports abdominal cramping after enema administration. This helps reduce the flow rate of the solution, potentially alleviating the cramping. Stopping the procedure and removing tubing (Choice B) would be too abrupt and may not address the issue. Increasing the flow of enema solution (Choice C) could exacerbate the cramping by adding more pressure. Continuing the enema at a slower rate (Choice D) might not provide immediate relief compared to lowering the height of the solution container.

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