Nursing Elites

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

• A. Below-the-knee amputation.
• B. 10 cm (4 in) laceration.
• C. Fractured tibia.
• D. 95% full-thickness body burn.

Correct answer: A

Rationale: A below-the-knee amputation requires immediate attention due to the risk of hemorrhage and shock, making it the highest priority. This type of injury can lead to significant blood loss and impaired perfusion, which can be life-threatening if not addressed promptly. While a 10 cm laceration, a fractured tibia, and a 95% full-thickness body burn are serious injuries requiring urgent care, they do not pose the same immediate threat to life as a below-the-knee amputation. The laceration may require suturing to control bleeding and prevent infection, the fractured tibia needs stabilization to prevent further damage and pain, and the burn necessitates immediate management to prevent complications, but they are not as acutely life-threatening as the amputation.

2. A client has developed phlebitis at the IV site. What should the nurse do immediately?

• A. Apply a warm compress over the IV site
• B. Discontinue the IV and notify the provider
• C. Monitor the site for signs of infection
• D. Administer an anti-inflammatory medication

Correct answer: B

Rationale: When a client develops phlebitis at the IV site, the immediate action the nurse should take is to discontinue the IV and notify the provider. Phlebitis is inflammation of the vein, and if left untreated, it can lead to serious complications such as infection, thrombosis, or sepsis. Removing the IV line helps prevent further irritation and infection. Applying a warm compress (Choice A) may provide some relief but does not address the root cause. Monitoring for signs of infection (Choice C) is important but not the immediate action needed to address phlebitis. Administering an anti-inflammatory medication (Choice D) may be prescribed by the provider but is not the first step in managing phlebitis.

3. A healthcare professional is managing a client with a wound infection. What is the priority action?

• A. Change the wound dressing every 12 hours
• B. Perform a wound culture before applying antibiotics
• C. Apply a wet-to-dry dressing to the wound
• D. Cleanse the wound with a solution of alcohol and water

Correct answer: B

Rationale: Performing a wound culture before applying antibiotics is crucial to identify the specific pathogen causing the infection. This helps in selecting the most effective antibiotics for treatment. Changing the wound dressing, applying a wet-to-dry dressing, or cleansing the wound are important interventions but should follow the assessment and identification of the infecting organism through a wound culture to guide appropriate treatment.

4. A nurse is assisting with the admission of a client who has major depressive disorder. Which of the following communication techniques should the nurse use to establish a trusting relationship with the client?

• A. Offer medical advice
• B. Offer general leads
• C. Ask open-ended questions
• D. Use assertive communication

Correct answer: B

Rationale: In the context of establishing a trusting relationship with a client who has major depressive disorder, offering general leads is the most appropriate communication technique. General leads encourage clients to express themselves by providing subtle prompts or cues, which can help build rapport and trust. Offering medical advice (Choice A) is not suitable as it may come across as imposing and could hinder the establishment of trust. Asking open-ended questions (Choice C) is beneficial for eliciting detailed responses but may not be as effective at initially establishing trust as general leads. Using assertive communication (Choice D) can be perceived as aggressive and intimidating, which is not conducive to building a trusting relationship with a client who has major depressive disorder.

5. What is the correct way to assess for pitting edema?

• A. Press over the bony area for 5 seconds and release
• B. Press over the skin for 10 seconds and check for discoloration
• C. Press the area and check for the presence of rash
• D. Press the skin and assess for rebound tenderness

Correct answer: A

Rationale: The correct way to assess for pitting edema is to press over a bony area, typically the tibia, for 5 seconds and then release. This allows for the identification of pitting edema, characterized by an indentation that persists for a few seconds. Choice B is incorrect as pitting edema assessment does not involve checking for discoloration. Choice C is incorrect as the presence of a rash is not indicative of pitting edema. Choice D is incorrect as rebound tenderness is a different assessment used for abdominal conditions, not for pitting edema.

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