Nursing Elites

1. A client is vomiting, and a nurse is providing care. Which of the following actions should the nurse take first?

• A. Administer an antiemetic to the client
• B. Notify housekeeping
• C. Prevent the client from aspirating
• D. Provide the client with an emesis basin

Correct answer: C

Rationale: Preventing aspiration is the priority when caring for a client who is vomiting to reduce the risk of pneumonia or other respiratory complications. Aspiration can occur when vomitus enters the airway, leading to respiratory distress. Ensuring the airway is protected during vomiting episodes is essential. Administering an antiemetic (Choice A) can be considered after addressing the immediate risk of aspiration. Notifying housekeeping (Choice B) and providing an emesis basin (Choice D) are important but are secondary to preventing aspiration, which is crucial for the client's safety and well-being.

2. What is the priority action for a patient with a fever?

• A. Administer an antipyretic medication as prescribed.
• B. Assess the patient's temperature regularly.
• C. Provide cooling measures such as a cool compress.
• D. Provide the patient with blankets for comfort.

Correct answer: B

Rationale: The priority action when a patient has a fever is to assess the patient's temperature regularly. Monitoring the temperature helps track the effectiveness of interventions and detect any worsening fever. Administering antipyretic medication (Choice A) should be done based on healthcare provider's orders after assessing the patient's condition. While providing cooling measures such as a cool compress (Choice C) can help reduce fever, assessing the temperature takes precedence. Providing blankets for comfort (Choice D) is not the priority when dealing with a fever.

3. The nurse is working on an orthopedic rehabilitation unit that requires lifting and positioning of patients. Which personal injury will the nurse most likely try to prevent?

• A. Hip
• B. Back
• C. Arm
• D. Ankle

Correct answer: B

Rationale: The correct answer is B: Back. Back injuries are most common during lifting and bending tasks, especially in an orthopedic unit. When lifting or repositioning patients, nurses must prioritize proper body mechanics to prevent strain on the back. Choices A, C, and D are less likely to occur as frequently as back injuries in this scenario because of the nature of the tasks involved in orthopedic patient care.

4. A patient has impaired skin integrity, and a nurse is providing care. What action should the nurse take to promote healing?

• A. Apply a dry, sterile dressing to the wound.
• B. Use sterile saline to clean the wound.
• C. Apply a warm compress to promote circulation.
• D. Keep the wound open to air for faster healing.

Correct answer: B

Rationale: The correct action to promote healing in a patient with impaired skin integrity is to use sterile saline to clean the wound. Sterile saline helps prevent infection and promotes healing of wounds by keeping the area clean. Applying a dry, sterile dressing (Choice A) may not be effective as it does not address the need for wound cleaning. Applying a warm compress (Choice C) may not be suitable for all types of wounds and could potentially cause harm. Keeping the wound open to air (Choice D) is generally not recommended as it can lead to infection and slow down the healing process.

5. A nurse is discussing organ donation with a newly licensed nurse. Which of the following statements should the nurse include in the teaching?

• A. To donate organs, a client must provide consent prior to death
• B. The transplant team will harvest the organs for donation from the donor client
• C. During admission, all clients over the age of 18 should be asked about their organ donor status
• D. The National Organ Transplant Act prohibits the sale and purchase of organs

Correct answer: C

Rationale: The correct answer is C. Asking clients over 18 about their organ donation status upon admission is essential to ensure their wishes are respected. Option A is incorrect because organ donation requires consent, not harvesting. Option B is incorrect because the transplant team, not the donor client's provider, is responsible for organ retrieval. Option D is incorrect because the National Organ Transplant Act prohibits the commercialization of organ transactions, not their donation.

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