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 nurse is assessing a newborn who was born vaginally with vacuum extractor assistance. The nurse notes swelling over the newborn's head that crosses the suture line. The nurse should identify the swelling as which of the following findings?

• A. Nevus simplex
• B. Caput succedaneum
• C. Cephalohematoma
• D. Erythema toxicum

Correct answer: B

Rationale: Caput succedaneum is the correct answer. It is the swelling of the soft tissues of the head that crosses suture lines, often resulting from pressure during delivery, especially with vacuum extraction. Nevus simplex (Choice A) is a pink or red birthmark that is flat and usually fades on its own. Cephalohematoma (Choice C) is a collection of blood between a baby's skull and the periosteum, often caused by birth trauma. Erythema toxicum (Choice D) is a common rash in newborns that is benign and typically resolves on its own. In this case, the description of swelling over the newborn's head crossing the suture line is characteristic of caput succedaneum, which is a common finding in newborns after vaginal delivery.

3. A nurse is assessing a client with pneumonia. Which of the following findings should the nurse expect?

• A. Bradycardia
• B. Increased respiratory rate
• C. Decreased temperature
• D. Elevated blood pressure

Correct answer: B

Rationale: The correct answer is B: Increased respiratory rate. In pneumonia, the body tries to compensate for the reduced ability to oxygenate the blood by increasing the respiratory rate. This helps to improve oxygen exchange. Bradycardia (Choice A) is not typically associated with pneumonia, as an increased heart rate is more common due to the stress on the body. Decreased temperature (Choice C) is not a typical finding in pneumonia, as infections usually cause a fever. Elevated blood pressure (Choice D) is not a common finding in pneumonia unless there are complications such as sepsis.

4. A nurse is providing discharge instructions for a client after surgery. Which of the following should be included?

• A. Resume normal activities immediately
• B. Monitor for signs of infection
• C. Avoid all physical activity for 1 month
• D. Take pain medications only as needed

Correct answer: B

Rationale: The correct answer is B: 'Monitor for signs of infection.' After surgery, it is essential for clients to watch for signs of infection, such as increased redness, swelling, or drainage at the incision site. Choice A is incorrect because resuming normal activities immediately after surgery can be harmful. Choice C is incorrect as complete avoidance of physical activity for a month is typically not necessary and can lead to complications like blood clots. Choice D is incorrect as taking pain medications only as needed may not provide adequate pain management post-surgery.

5. A nurse is caring for a client who is taking warfarin. The nurse notes that the client has a new prescription for amoxicillin. Which of the following laboratory tests should the nurse monitor closely?

• A. Serum potassium
• B. Prothrombin time (PT)
• C. Serum sodium
• D. Blood glucose

Correct answer: B

Rationale: The correct answer is B: Prothrombin time (PT). Amoxicillin can potentiate the effects of warfarin, increasing the risk of bleeding. Monitoring the prothrombin time (PT) is crucial in this situation to assess the client's clotting ability. Choices A, C, and D are incorrect because amoxicillin's interaction with warfarin does not directly impact serum potassium, serum sodium, or blood glucose levels.

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