Nursing Elites

1. A client has burns to his face, ears, and eyelids. What is the priority finding for the nurse to report to the provider?

• A. Urinary output of 25 mL/hr
• B. Difficulty swallowing
• C. Heart rate of 122/min
• D. Pain level of 6 on a scale of 0 to 10

Correct answer: B

Rationale: When a client has burns involving the face, ears, and eyelids, the priority finding to report to the provider is difficulty swallowing. This symptom could indicate potential airway compromise or swelling in the throat, which can lead to serious complications. Monitoring and addressing this issue promptly is crucial to ensure the client's airway remains patent and secure.

2. In an emergency department, a healthcare provider is preparing to care for a client with multiple system trauma following a motor vehicle crash. What should be the priority focus of care?

• A. Airway protection
• B. Decreasing intracranial pressure
• C. Stabilizing cardiac arrhythmias
• D. Preventing musculoskeletal disability

Correct answer: A

Rationale: In a client with multiple system trauma, airway protection is the priority focus of care. Ensuring a patent airway is crucial for oxygenation and ventilation, which are essential for maintaining vital functions. Without a clear airway, the client's oxygenation and ventilation could be compromised, leading to severe consequences. While decreasing intracranial pressure, stabilizing cardiac arrhythmias, and preventing musculoskeletal disability are important aspects of care, ensuring airway protection takes precedence in this emergency situation.

3. A nurse in a provider's office is assessing a client. Which of the following findings is not a manifestation of pulmonary tuberculosis?

• A. Night sweats
• B. Low-grade fever
• C. Weight gain
• D. Blood in the sputum

Correct answer: C

Rationale:

4. A healthcare provider is assessing a client who had a myocardial infarction. Upon auscultating heart sounds, the provider hears the following sound. What action by the provider is most appropriate?

• A. Assess the client's lung sounds.
• B. Call the Rapid Response Team.
• C. Have the client sit upright.
• D. Listen to the client's lung sounds.

Correct answer: A

Rationale: The sound described is an S3 heart sound, which can indicate heart failure. The next appropriate action for the provider is to listen to the client's lung sounds. Lung sounds can provide additional information about the client's condition, especially when abnormal heart sounds are present. Calling the Rapid Response Team is not warranted based solely on the heart sound assessment. Having the client sit upright is not directly related to addressing the abnormal heart sound.

5. Which action best demonstrates respect for autonomy when working with a client?

• A. Asks if the client has questions before signing a consent form
• B. Provides the client with accurate information when questioned
• C. Honors the promises made to the client and family
• D. Ensures fair treatment of the client compared to others

Correct answer: A

Rationale: Respect for autonomy involves allowing individuals to make decisions about their care. By asking if the client has questions before signing a consent form, the nurse is respecting the client's right to make informed choices and decisions regarding their healthcare. This action supports the principle of self-determination and autonomy in healthcare decision-making.

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