Nursing Elites

1. In an emergency department following a community disaster, a healthcare provider is performing triage for multiple clients. To which of the following types of injuries should the provider assign the highest priority?

• A. Below-the-knee amputation.
• B. Fractured tibia.
• C. 95% full-thickness body burn.
• D. 10 cm laceration to the forearm.

Correct answer: A

Rationale: During disaster triage, clients with severe injuries that are immediately life-threatening and have a high likelihood of mortality without intervention are assigned the highest priority. A below-the-knee amputation falls into this category as it indicates a critical injury that requires immediate attention to prevent further complications or loss of life. Fractured tibia, a 95% full-thickness body burn, and a 10 cm laceration to the forearm, while serious, do not pose the same level of immediate life-threatening risk as a below-the-knee amputation in the context of disaster triage.

2. When caring for a client with asthma experiencing an acute exacerbation, which medication should the nurse administer first?

• A. Montelukast
• B. Salmeterol
• C. Albuterol
• D. Fluticasone

Correct answer: C

Rationale: During an acute asthma exacerbation, the priority is to quickly relieve bronchoconstriction and improve airflow. Albuterol is a short-acting bronchodilator that acts rapidly to dilate the airways, making it the first-line medication for acute symptom relief. Montelukast is a leukotriene receptor antagonist used for long-term asthma control, not for immediate relief. Salmeterol is a long-acting bronchodilator used for maintenance therapy, not for acute exacerbations. Fluticasone is an inhaled corticosteroid that reduces airway inflammation and is also used for long-term control, not for immediate relief during an exacerbation.

3. A client has a new prescription for digoxin. Which of the following statements should the nurse include?

• A. You should take this medication on an empty stomach.
• B. You should avoid taking this medication with antacids.
• C. Take your pulse before taking this medication.
• D. You should contact your provider if you experience visual changes.

Correct answer: C

Rationale: The correct statement for the nurse to include when teaching a client about digoxin is to 'Take your pulse before taking this medication.' This is essential because clients taking digoxin need to monitor their pulse to detect signs of bradycardia, a common adverse effect of the medication. Option A is incorrect because digoxin is usually recommended to be taken with food to avoid gastrointestinal upset. Option B is incorrect because antacids can interfere with the absorption of digoxin. Option D is incorrect because contacting the provider for visual changes is important, but monitoring the pulse is crucial for digoxin administration.

4. A nurse is reviewing the laboratory results of a client who has heart failure. Which of the following findings should the nurse report to the provider?

• A. Potassium 4.0 mEq/L
• B. Hemoglobin 12 g/dL
• C. BUN 18 mg/dL
• D. Sodium 137 mEq/L

Correct answer: B

Rationale: The correct answer is B: Hemoglobin 12 g/dL. In a client with heart failure, a decrease in hemoglobin levels can indicate anemia, which can exacerbate heart failure symptoms. Reporting this finding to the provider is crucial for appropriate management. Choice A, Potassium 4.0 mEq/L, is within the normal range (3.5-5.0 mEq/L) and does not typically require immediate reporting. Choice C, BUN 18 mg/dL, and Choice D, Sodium 137 mEq/L, are also within normal ranges and not directly related to heart failure management. Therefore, the hemoglobin level is the most critical finding to report in this scenario.

5. A nurse is assessing a newborn immediately following birth. Which of the following findings should the nurse report to the provider?

• A. Acrocyanosis
• B. Vernix caseosa
• C. A respiratory rate of 50/min
• D. Heart rate of 160/min

Correct answer: D

Rationale: The correct answer is D, a heart rate of 160/min. A heart rate of 160/min in a newborn exceeds the normal range and could indicate potential issues that need further evaluation by the provider. Acrocyanosis (choice A) is a common finding in newborns and is not concerning. Vernix caseosa (choice B) is a white, cheesy substance found on newborn skin and is a normal finding. While a respiratory rate of 50/min (choice C) is slightly elevated, it is not as concerning as a high heart rate in a newborn.

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