Nursing Elites

1. A young adult female client is seen in the emergency department for a minor injury following a motor vehicle collision. She states she is very angry at the person who hit her car. What is the best nursing response?

• A. You are lucky to be alive. Be grateful no one was killed.'
• B. I understand your car was not seriously damaged.'
• C. You are upset that this incident has brought you here.'
• D. Have you ever been in the emergency department before?'

Correct answer: C

Rationale: Validating the client's feelings can help her express and manage her emotions effectively.

2. A client is admitted with suspected meningitis. Which assessment finding requires immediate intervention?

• A. Headache.
• B. Fever.
• C. Nuchal rigidity.
• D. Seizures.

Correct answer: D

Rationale: Seizures in a client with suspected meningitis indicate increased intracranial pressure or other complications requiring immediate intervention. Seizures can lead to further neurological damage and need prompt management to prevent adverse outcomes. Therefore, addressing seizures promptly is crucial in the care of a client with suspected meningitis.

3. A client returns to the unit after a neck dissection. The surgeon placed a Jackson-Pratt drain in the wound. When assessing the wound drainage over the first 24 postoperative hours, what finding would prompt the nurse to notify the health care provider immediately?

• A. Presence of small blood clots in the drainage
• B. 60 mL of milky or cloudy drainage
• C. Spots of drainage on the dressings surrounding the drain
• D. 120 mL of serosanguinous drainage

Correct answer: B

Rationale: Milky or cloudy drainage can indicate infection or lymphatic leakage, which requires immediate attention. This finding may suggest a serious complication post neck dissection, warranting prompt notification of the healthcare provider for further evaluation and intervention.

4. A client with myelogenous leukemia is receiving an autologous bone marrow transplantation (BMT). What is the priority intervention that the nurse should implement when the bone marrow is repopulating?

• A. Administer sargramostim (Leukine, Prokine).
• B. Infuse PRBC and platelet transfusions.
• C. Give parenteral prophylactic antibiotics.
• D. Maintain a protective isolation environment.

Correct answer: D

Rationale: Maintaining a protective isolation environment is crucial during the repopulation of bone marrow post-transplant to reduce the risk of infections. The client's immune system is compromised during this period, making them highly susceptible to infections. By implementing protective isolation measures, the nurse can help prevent exposure to pathogens, safeguarding the client's health and supporting the success of the transplantation.

5. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy. Which intervention should the nurse implement to ensure the client's safety?

• A. Increase the oxygen flow rate to 6 liters/minute if the client is short of breath.
• B. Instruct the client to breathe deeply and cough frequently.
• C. Use a nasal cannula to deliver oxygen at a low flow rate.
• D. Encourage the client to remove the oxygen when eating or drinking.

Correct answer: C

Rationale: Using a nasal cannula to deliver oxygen at a low flow rate is the appropriate intervention for clients with COPD receiving oxygen therapy. High flow rates can lead to respiratory depression in COPD patients. This intervention helps maintain a safe and controlled oxygen delivery to prevent potential complications associated with high oxygen flow rates.

Similar Questions