Nursing Elites

1. A nurse in the emergency department is caring for a patient who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the patient’s care, the nurse should identify which of the following risks as the priority for assessment and intervention?

• A. Infection
• B. Airway obstruction
• C. Fluid imbalance
• D. Pain management

Correct answer: B

Rationale: When a patient has extensive burns involving the head, neck, and chest, the priority concern is airway obstruction. The proximity of the burns to the airway can lead to swelling and compromise the patient's ability to breathe. In this situation, ensuring a clear airway and adequate oxygenation takes precedence over other risks such as infection, fluid imbalance, or pain management. While these are also important considerations in burn care, the immediate threat to the patient's life from airway compromise makes it the priority for assessment and intervention.

2. A healthcare provider is reviewing the health history of an older adult who has a hip fracture. The healthcare provider should identify what as a risk factor for developing pressure injuries?

• A. Advanced age
• B. Urinary incontinence
• C. Regular skin assessments
• D. Adequate hydration

Correct answer: B

Rationale: Urinary incontinence is a significant risk factor for skin breakdown and pressure injuries. It can lead to prolonged skin exposure to moisture and irritants, increasing the susceptibility to pressure injuries. Advanced age (Choice A) is a risk factor due to changes in skin integrity and decreased tissue viability, but it is not as direct a risk factor as urinary incontinence. Regular skin assessments (Choice C) are important for early detection and prevention but are not a risk factor themselves. Adequate hydration (Choice D) is essential for overall skin health but is not a direct risk factor for pressure injuries.

3. A nurse is preparing to administer a dose of enoxaparin. Which of the following actions should the nurse take?

• A. Administer it intramuscularly
• B. Monitor APTT levels
• C. Give it in the abdomen
• D. Administer rapidly

Correct answer: C

Rationale: The correct answer is to give enoxaparin in the abdomen. Enoxaparin is usually administered subcutaneously in the abdomen to avoid muscle irritation. Choice A is incorrect because enoxaparin should not be administered intramuscularly. Choice B is incorrect as monitoring APTT levels is not directly related to administering enoxaparin. Choice D is incorrect as enoxaparin should be administered slowly to prevent bruising or bleeding at the injection site.

4. A postpartum client's fundus is firm, 3 cm above the umbilicus, and displaced to the right. Which of the following interventions should the nurse take?

• A. Massage the fundus
• B. Administer oxytocin
• C. Assist the client to void then reassess the fundus
• D. Notify the healthcare provider

Correct answer: C

Rationale: The correct intervention for a postpartum client with a firm, displaced fundus is to assist the client to void then reassess the fundus. Displacement of the uterus to the right is often a sign of bladder distention, which can prevent the uterus from contracting properly and increase the risk of postpartum hemorrhage. By helping the client to void, the nurse can alleviate the bladder distention, allowing the uterus to contract effectively. Massaging the fundus (Choice A) may not address the underlying issue of bladder distention. Administering oxytocin (Choice B) is not indicated without assessing and addressing the cause of the displacement. Notifying the healthcare provider (Choice D) is premature before implementing initial nursing interventions to address the potential cause of the displaced fundus.

5. A client with a history of seizures is being cared for by a nurse. Which of the following interventions should the nurse prioritize?

• A. Ensure the environment is safe
• B. Administer medications as prescribed
• C. Monitor for signs of infection
• D. Educate the client about triggers

Correct answer: A

Rationale: The nurse should prioritize ensuring the environment is safe for a client with a history of seizures. This intervention is crucial to prevent injury during a seizure. Administering medications as prescribed is important but ensuring a safe environment takes precedence to prevent harm. Monitoring for signs of infection and educating the client about triggers are also essential aspects of care but are not the priority when considering the immediate safety of the client during a seizure.

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