Nursing Elites

1. A patient presents with vesicles covering the upper torso. Which of the following situations could cause this condition?

• A. Knife fight
• B. Auto accident
• C. Sunburn
• D. Fungal infection

Correct answer: C

Rationale: Vesicles are fluid-filled blisters. In the context of the upper torso, the presentation of vesicles suggests a second-degree sunburn. Sunburn can cause blistering, leading to the formation of vesicles. Choice A, 'Knife fight,' does not align with the presentation of vesicles on the upper torso due to trauma. Choice B, 'Auto accident,' is more likely to cause abrasions or bruises rather than vesicles. Choice D, 'Fungal infection,' typically presents with other symptoms such as redness, itching, or scaling, but not vesicles on the upper torso.

2. The nurse is caring for a woman 2 hours after a vaginal delivery. Documentation indicates that the membranes were ruptured for 36 hours prior to delivery. What are the priority nursing diagnoses at this time?

• A. Altered tissue perfusion
• B. Risk for fluid volume deficit
• C. High risk for hemorrhage
• D. Risk for infection

Correct answer: D

Rationale: The correct answer is 'Risk for infection.' When the membranes are ruptured for more than 24 hours prior to birth, there is a significantly increased risk of infection for both the mother and the newborn. Monitoring for signs of infection, such as fever, foul-smelling vaginal discharge, and uterine tenderness, is crucial. Option A, 'Altered tissue perfusion,' is not the priority in this scenario as infection risk takes precedence due to the prolonged rupture of membranes. Option B, 'Risk for fluid volume deficit,' is less of a priority compared to the immediate risk of infection. Option C, 'High risk for hemorrhage,' is not the priority concern at this time based on the information provided.

3. The healthcare provider is reviewing the lab results of a patient who has presented in the Emergency Room. The lab results show that the BNP (B-type Natriuretic Peptide) value is 615 pg/ml. What would the healthcare provider take as the priority action?

• A. Call for a cardiac evaluation and implement appropriate measures
• B. Check the patient's oxygen saturation
• C. Inform the physician about the elevated BNP level
• D. Encourage the patient to limit physical activity

Correct answer: B

Rationale: An elevated BNP level is indicative of decreased cardiac output, suggesting potential heart failure. In this scenario, the priority action is to check the patient's oxygen saturation. Oxygen saturation assessment is crucial to ensure adequate oxygenation and respiratory function, which is essential in managing cardiac conditions. Calling for a cardiac evaluation and implementing appropriate measures may be necessary but is not the immediate priority without assessing oxygen saturation. Informing the physician about the elevated BNP level can be important for further management but is not the immediate action needed in this situation. Encouraging the patient to limit physical activity might be a consideration later but is not the priority action when dealing with a potential cardiac emergency.

4. The nurse is planning care for a client during the acute phase of a sickle cell vasoocclusive crisis. Which of the following actions would be most appropriate?

• A. Fluid restriction to 1000cc per day
• B. Ambulate in the hallway 4 times a day
• C. Administer analgesic therapy as ordered
• D. Encourage increased caloric intake

Correct answer: C

Rationale: Administering analgesic therapy as ordered is the most appropriate action during the acute phase of a sickle cell vasoocclusive crisis. In this phase, the primary focus is on managing the severe pain experienced by the individual. Analgesic therapy helps alleviate the pain and discomfort associated with the crisis. The other options are not the priority during this phase. Fluid restriction is not recommended as hydration is crucial in managing a vasoocclusive crisis. Ambulation may worsen the pain and should be minimized during this phase. Encouraging increased caloric intake is not directly related to managing the acute phase of a vasoocclusive crisis.

5. The nurse cares for a patient who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider?

• A. Oxygen saturation is 88%.
• B. Blood pressure is 145/90 mm Hg.
• C. Respiratory rate is 22 breaths/minute when lying flat.
• D. Pain level is 5 (on a 0 to 10 scale) with a deep breath.

Correct answer: A

Rationale: The correct answer is 'Oxygen saturation is 88%.' Following a thoracentesis, oxygen saturation should improve. A saturation of 88% suggests a potential complication like pneumothorax. While the other assessment findings are important, the priority is to address the low oxygen saturation to prevent further complications. High blood pressure and respiratory rate may also need attention, but the immediate concern is the oxygen saturation level. Pain level, though significant for the patient's comfort, takes lower priority compared to the potential life-threatening issue of hypoxia.

Similar Questions