Nursing Elites

1. A triage nurse has four clients arrive in the emergency department within 15 minutes. Which client should the triage nurse send back to be seen first?

• A. A 2-month-old infant with a history of rolling off the bed and having a bulging fontanelle with crying
• B. A teenager who suffered singed facial hair while camping
• C. An elderly client with complaints of frequent liquid brown-colored stools
• D. A middle-aged client with intermittent pain behind the right scapula

Correct answer: B

Rationale: The correct answer is the teenager who suffered singed facial hair while camping. This client is in the greatest danger with a potential risk of respiratory distress. Singed facial hair indicates exposure to heat or fire in close range, which could have caused serious damage to the interior of the lungs. It's crucial to prioritize this client as the interior lining of the lungs has no nerve fibers, so swelling may not be immediately noticeable. The other choices, while concerning, do not present an immediate life-threatening situation. The infant's condition may be serious but does not pose an immediate danger of respiratory distress. The elderly client's symptoms could indicate gastrointestinal issues, which are important but not as urgent as potential respiratory compromise. The middle-aged client's pain behind the right scapula, while uncomfortable, does not indicate an acute life-threatening condition requiring immediate attention.

2. The nurse is conducting a health fair for older adults. Which statement is true regarding vital sign measurements in aging adults?

• A. The pulse is easier to palpate due to the rigidity of the blood vessels.
• B. An increased respiratory rate and a shallower inspiratory phase are expected findings.
• C. A widened pulse pressure occurs from changes in the systolic and diastolic blood pressures.
• D. Changes in the body's temperature regulatory mechanism decrease the older adult's likelihood of developing a fever.

Correct answer: B

Rationale: Aging causes a decrease in vital capacity and decreased inspiratory reserve volume. As a result, the examiner may observe a shallower inspiratory phase and an increased respiratory rate in older adults. Contrary to common belief, the increased rigidity of arterial walls actually makes the pulse easier to palpate in aging adults. Pulse pressure is widened, not decreased, due to changes in systolic and diastolic blood pressures. Furthermore, changes in the body's temperature regulatory mechanism make older individuals less likely to develop a fever but more susceptible to hypothermia.

3. When percussing over the lungs of a 4-year-old child, the nurse hears bilateral loud, long, and low tones. How should the nurse proceed?

• A. Palpate over the area for increased pain and tenderness.
• B. Ask the child to take shallow breaths and percuss over the area again.
• C. Refer the child to a specialist because of an increased amount of air in the lungs.
• D. Consider this finding as normal for a child this age and proceed with the examination.

Correct answer: D

Rationale: In pediatric patients, loud, long, and low tones heard when percussing over the lungs are normal findings. These percussion notes are characteristic of a child's lung due to its thin chest wall and increased air content. It is unnecessary to palpate for pain and tenderness, ask the child to take shallow breaths and repeat the percussion, or refer the child to a specialist. Therefore, the correct action is to consider these findings as normal for the child's age and continue with the examination.

4. The Atlas and the Axis are:

• A. found in the vertebrae.
• B. described as being cervical.
• C. the first two bones that form the column for the spine on the superior aspect.
• D. All of the above.

Correct answer: D

Rationale: The Atlas and the Axis are the first two cervical vertebrae, designated as C1 and C2. The Atlas (C1) supports the skull, while the Axis (C2) allows for rotation of the skull. Therefore, all the statements in choices A, B, and C are correct, making 'All of the above' the correct answer. Choice A is correct as the Atlas and Axis are indeed found in the vertebrae. Choice B is correct as they are the first two cervical vertebrae. Choice C is correct as these bones form the superior aspect of the spine.

5. The nurse is caring for a patient who has a right-sided chest tube after a right lower lobectomy. Which nursing action can the nurse delegate to the unlicensed assistive personnel (UAP)?

• A. Document the amount of drainage every eight hours
• B. Obtain samples of drainage for culture from the system
• C. Assess patient pain level associated with the chest tube
• D. Check the water-seal chamber for the correct fluid level

Correct answer: A

Rationale: The correct answer is to document the amount of drainage every eight hours. UAP education typically includes tasks related to documentation of intake and output. Obtaining samples of drainage for culture and assessing patient pain level are nursing responsibilities that require licensed nursing personnel's education and scope of practice. Checking the water-seal chamber for the correct fluid level also falls under the nursing role, as it involves monitoring and maintaining the chest tube system, which requires nursing knowledge and training.

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