Nursing Elites

1. In a disaster where a building has collapsed, which victim should a nurse attend to first?

• A. A victim who has died of multiple serious injuries
• B. A victim with a partial amputation of a leg who is bleeding profusely
• C. An alert victim who has numerous bruises on the arms and legs
• D. A hysterical victim who has sustained a head injury

Correct answer: B

Rationale: In a disaster situation like a building collapse, the nurse should attend to the victim with a partial amputation of a leg who is bleeding profusely first. This victim is at immediate risk of severe blood loss, which can be life-threatening. It is crucial to address life-threatening injuries like severe bleeding before attending to other less urgent cases. The victim with the amputation requires immediate intervention to control bleeding and stabilize their condition. Victims who are already deceased or have less urgent injuries can be attended to after addressing the critical cases.

2. A healthcare professional is assessing a patient with pneumonia. Which finding is most concerning?

• A. Fever of 101°F.
• B. Blood pressure of 140/90 mmHg.
• C. Heart rate of 95 beats per minute.
• D. Crackles heard in the lung bases.

Correct answer: D

Rationale: Crackles heard in the lung bases are most concerning in a patient with pneumonia as they suggest fluid accumulation in the lungs, indicating possible severe infection or respiratory distress. Prompt intervention is required to prevent further complications.\n\nChoice A, fever of 101°F, is common in infections like pneumonia but may not be as immediately concerning as crackles indicating fluid in the lungs.\n\nChoice B, a blood pressure of 140/90 mmHg, is within normal limits and not directly indicative of pneumonia severity.\n\nChoice C, a heart rate of 95 beats per minute, is slightly elevated but not as critical as crackles suggesting fluid in the lungs.

3. Which of the following statements reflects the principles of sterile technique?

• A. Sterile objects that come in contact with unsterile objects are to be considered contaminated.
• B. Items in a sterile package must be used immediately once the package has been opened; otherwise, they are considered contaminated.
• C. Any part of a sterile field that hangs below the top of the table is sterile as long as it is not touched.
• D. The edge of a sterile field and a border 1 inch (2.5 cm) inward is unsterile.

Correct answer: A

Rationale: The correct statement reflecting the principles of sterile technique is that sterile objects that come in contact with unsterile objects are considered contaminated. This principle is crucial in maintaining asepsis during medical procedures. Choice B is incorrect because items in a sterile package should only be used if they remain sterile; opening the package does not automatically contaminate the items. Choice C is incorrect as any part of a sterile field that hangs below the top of the table is considered unsterile. Choice D is incorrect as the edge of a sterile field and a border inward are typically considered unsterile to maintain the integrity of the sterile area.

4. A nurse is providing discharge teaching to a client following a cataract extraction. Which of the following instructions should the nurse include?

• A. Bend at the waist when picking up objects.
• B. Avoid lying on the operative side.
• C. Avoid lifting more than 10 lb.
• D. Apply ice to the affected eye.

Correct answer: C

Rationale: The correct answer is C: 'Avoid lifting more than 10 lb.' After a cataract extraction, the nurse should instruct the client to avoid lifting heavy objects to prevent increased intraocular pressure, which could lead to complications. Choices A, B, and D are incorrect. A - 'Bend at the waist when picking up objects' can increase intraocular pressure; B - 'Avoid lying on the operative side' is not a specific concern related to cataract extraction; D - 'Apply ice to the affected eye' is not a standard post-cataract extraction instruction.

5. A patient is experiencing shortness of breath. What is the nurse's immediate action?

• A. Assist the patient into a high Fowler's position.
• B. Administer oxygen at 2 liters per minute via nasal cannula.
• C. Encourage the patient to take deep breaths and cough.
• D. Assess the patient's lung sounds.

Correct answer: B

Rationale: Administering oxygen at 2 liters per minute via nasal cannula is the immediate action for a patient experiencing shortness of breath. This intervention helps to improve oxygenation and relieve respiratory distress promptly. Placing the patient in a high Fowler's position (choice A) may also be beneficial but providing oxygen takes precedence in this scenario to address the underlying hypoxemia. Encouraging deep breaths and coughing (choice C) may not be appropriate as the first action, especially without assessing the patient first. Assessing lung sounds (choice D) is essential but should follow the initial intervention of administering oxygen.

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