Nursing Elites

1. During a petit mal seizure in the clinic, what should be the highest priority?

• A. Provide a safe environment free of obstructions in the immediate area
• B. Call a code
• C. Contact the patient's physician
• D. Prevent excessive movement of the extremities

Correct answer: A

Rationale: During a petit mal seizure, the highest priority is to provide a safe environment free of obstructions in the immediate area. This action aims to prevent injuries to the patient during the seizure. While calling a code or contacting the patient's physician may be necessary at some point, immediate safety measures take precedence. Preventing excessive movement of the extremities is relevant but ensuring a safe environment is crucial to avoid harm during the seizure.

2. A 15-year-old high school wrestler has been taking diuretics to lose weight to compete in a lower weight class. Which of the following medical tests is most likely to be given?

• A. Lab values of Potassium and Sodium
• B. Lab values of Glucose and Hemoglobin
• C. ECG
• D. CT scan

Correct answer: A

Rationale: Diuretics can disrupt the sodium and potassium balance, potentially leading to cardiac complications. Monitoring the lab values of potassium and sodium is crucial to assess electrolyte imbalances due to diuretic use. Testing glucose and hemoglobin levels is not directly related to diuretic use in this context. An ECG would be indicated if there were signs or symptoms of cardiac abnormalities, but it is not the primary test to monitor the effects of diuretics. A CT scan is not typically used to assess electrolyte imbalances caused by diuretics.

3. The nurse is preparing for a dressing change on a full thickness burn to the flank area. The orders include irrigating the wound with each dressing change. To irrigate the wound, what will the nurse use?

• A. Sterile saline
• B. Distilled water
• C. Betadine scrub
• D. Tap water

Correct answer: A

Rationale: When irrigating a wound, especially in the case of a full-thickness burn, it is crucial to use a solution that is gentle and non-irritating to the tissues. Sterile saline is the preferred choice for wound irrigation as it is isotonic and does not cause additional damage to the already compromised tissue. Distilled water lacks the electrolytes present in saline, Betadine scrub is not used for irrigation due to its potential to be cytotoxic, and tap water may introduce contaminants and microorganisms to the wound.

4. A nurse is teaching a client newly diagnosed with Emphysema about the disease process. Which of the following statements best explains the problems associated with emphysema and could be adapted for use in the nurse's discussion with the client?

• A. Hyperactivity of the medium-sized bronchi caused by an inflammatory response leads to wheezing and tightness in the chest.
• B. Larger than normal air spaces and loss of elastic recoil cause air to be trapped in the lung and collapse airways.
• C. Vasodilation, congestion, and mucosal edema cause a chronic cough and sputum production.
• D. Chloride is not being transported properly, producing excess absorption of water and sodium, and thick viscous mucus

Correct answer: B

Rationale: The correct answer is: 'Larger than normal air spaces and loss of elastic recoil cause air to be trapped in the lung and collapse airways.' Emphysema is a breakdown of the elastin and fiber network of the alveoli where the alveoli enlarge or the walls are destroyed. This alveolar destruction leads to the formation of larger-than-normal air spaces. Emphysema is one of a group of pulmonary diseases of a chronic nature characterized by increased resistance to airflow; the entity is part of chronic obstructive pulmonary disease (COPD). Choice A is incorrect because emphysema is not primarily characterized by hyperactivity of the medium-sized bronchi causing wheezing and tightness in the chest. Choice C is incorrect because vasodilation, congestion, and mucosal edema are not the primary mechanisms involved in emphysema, and they do not directly lead to chronic cough and sputum production. Choice D is incorrect because emphysema is not related to chloride transport issues and thick viscous mucus production.

5. When auscultating breath sounds, the nurse auscultates over the following locations:

• A. Trachea and lateral areas of thoracic cage
• B. Anterior and posterior aspects of all lung fields
• C. The mid section as well as the lateral section of the lungs
• D. The mid-clavicular to mid-axillary lines comparing side to side

Correct answer: B

Rationale: The correct answer is B: Anterior and posterior aspects of all lung fields. When auscultating breath sounds, it is essential to listen to the front (anterior) and back (posterior) aspects of all lung fields. This comprehensive approach allows for a thorough assessment of breath sounds throughout the lungs. Choices A, C, and D are incorrect. Choice A is too limited as it only focuses on the trachea and lateral areas, not covering all lung fields. Choice C is also too limited, referring to specific sections of the lungs (mid section and lateral section). Choice D is incorrect as it suggests comparing specific lines on the chest (mid-clavicular to mid-axillary), which is not a standard practice for auscultating breath sounds.

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