Nursing Elites

1. A healthcare professional is assessing a client following a gunshot wound to the chest. For which of the following findings should the healthcare professional not monitor to detect a pneumothorax?

• A. Tachypnea
• B. Deviation of the trachea
• C. Bradycardia
• D. Pleuritic pain

Correct answer: C

Rationale: Bradycardia, which is a slow heart rate, is not typically associated with a pneumothorax. In a pneumothorax, the presence of air in the pleural space can lead to lung collapse, causing symptoms such as tachypnea (rapid breathing), deviation of the trachea, and pleuritic pain. Monitoring for bradycardia may not be as relevant in this context as it is not a typical indicator of a pneumothorax.

2. A healthcare professional is completing an incident report after a client fall. Which of the following competencies of Quality and Safety Education for Nurses is the professional demonstrating?

• A. Quality improvement
• B. Patient-centered care
• C. Evidence-based practice
• D. Informatics

Correct answer: A

Rationale: Completing an incident report after a client fall aligns with the competency of quality improvement, which focuses on identifying system errors and implementing changes to improve patient outcomes and safety. Patient-centered care emphasizes involving patients in their care decisions, evidence-based practice involves integrating research and clinical expertise, and informatics involves using technology to improve patient care. In this scenario, the emphasis is on the process of improving quality and safety related to the incident.

3. To assess the kidney function of a patient with an indwelling urinary (Foley) catheter, the nurse measures the hourly urine output. When should she notify the physician?

• A. Less than 30 ml/hour
• B. 64 ml in 2 hours
• C. 90 ml in 3 hours
• D. 125 ml in 4 hours

Correct answer: A

Rationale: Notifying the physician is necessary when the urine output is less than 30 ml/hour as it indicates impaired kidney function. Adequate urine output is essential for monitoring kidney function, and a urine output less than 30 ml/hour could suggest potential renal issues that require medical attention.

4. A client with depression reports taking St. John's wort along with citalopram. The nurse should monitor the client for which of the following conditions as a result of an interaction between these substances?

• A. Serotonin syndrome
• B. Tardive dyskinesia
• C. Pseudoparkinsonism
• D. Acute dystonia

Correct answer: A

Rationale: When St. John's wort, an herbal supplement, is taken with citalopram, a selective serotonin reuptake inhibitor (SSRI), there is a risk of serotonin syndrome. Serotonin syndrome is a serious condition that can occur when there is an excess of serotonin in the body, leading to symptoms such as confusion, hallucinations, rapid heart rate, increased body temperature, and more. Monitoring for serotonin syndrome is crucial when these substances are taken together to prevent any potential harm to the client.

5. A client has diaper dermatitis. Which of the following actions should the nurse take?

• A. Apply zinc oxide ointment to the irritated area.
• B. Wipe stool from the skin using store-bought baby wipes.
• C. Apply talcum powder to the irritated area.
• D. None of the above

Correct answer: A

Rationale: Diaper dermatitis, also known as diaper rash, is a common condition in babies or clients who wear diapers. The primary intervention for diaper dermatitis is to apply a protective barrier cream, such as zinc oxide ointment, to the irritated area. This helps to protect the skin from irritants and promotes healing. Wiping stool from the skin using baby wipes may further irritate the skin, and talcum powder is no longer recommended due to potential respiratory risks when inhaled. Therefore, the correct action for the nurse in this scenario is to apply zinc oxide ointment to the irritated area.

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