Nursing Elites

1. What type of injury is associated with acute hyphema?

• A. orthopedic
• B. eye
• C. insect sting or snakebite
• D. gynecological trauma

Correct answer: B

Rationale: Acute hyphema is associated with an eye injury, typically resulting from blunt trauma. The presence of blood in the anterior chamber of the eye causes a half-moon appearance or a horizontal line across the globe when the client is upright. Choices A, C, and D are incorrect because acute hyphema is not related to orthopedic injuries, insect stings, snakebites, or gynecological trauma.

2. In an emergency situation, the nurse determines whether a client has an airway obstruction. Which of the following does the nurse assess?

• A. ability to speak
• B. ability to hear
• C. oxygen saturation
• D. adventitious breath sounds

Correct answer: A

Rationale: In an emergency situation to assess for airway obstruction, the nurse should prioritize assessing the client's ability to speak. If a client can speak, it indicates that the airway is patent and not completely obstructed, allowing air to pass through the vocal cords for speech production. Choices B, C, and D are not the primary assessments for determining airway obstruction. Assessing the ability to hear is not directly related to an airway obstruction. While oxygen saturation and adventitious breath sounds are important in respiratory assessments, they are not the initial indicators of an airway obstruction. Oxygen saturation reflects the amount of oxygen in the blood, and adventitious breath sounds refer to abnormal lung sounds that may indicate conditions like pneumonia or bronchitis, but they do not specifically confirm airway patency.

3. A client with a left arm fracture complains of severe diffuse pain that is unrelieved by pain medication. On further assessment, the nurse notes that the client experiences increased pain during passive motion compared with active motion of the left arm. Based on these assessment findings, which action should the nurse take first?

• A. Contacting the health care provider
• B. Checking if it is time for more pain medication
• C. Encouraging the client to continue active range of motion exercises of the left arm
• D. Repositioning the client for comfort

Correct answer: A

Rationale: The correct answer is to contact the health care provider. The client with early acute compartment syndrome typically complains of severe diffuse pain that is unrelieved by pain medication. Additionally, the affected client experiences greater pain during passive motion compared to active motion. In this situation, it is crucial to notify the health care provider immediately for further evaluation and intervention. Contacting the health care provider is essential to ensure timely diagnosis and appropriate management of the condition. Checking for more pain medication, encouraging active range of motion exercises, or repositioning the client may not address the underlying issue of acute compartment syndrome and could delay necessary interventions. Therefore, the priority action should be to involve the healthcare provider for prompt assessment and treatment.

4. A nurse discharge planner is preparing a client for discharge from an acute care setting. The nurse assesses that skilled home care services are clinically indicated. This assessment is based on all of the following indicators except:

• A. the client has been admitted to the hospital three times in the last 2 months.
• B. the client has a Foley catheter.
• C. the client's family is available to care for him 24 hours a day.
• D. the client is ordered to continue IV antibiotics 5 days post discharge.

Correct answer: V

Rationale: Family availability to provide care and assistance is not an indicator for skilled home care services. In fact, the nurse might see an opportunity for family education to meet the client's needs so that less community support is needed. This should be discussed and negotiated with the family. Frequent hospital readmissions indicate that the client has not been able to manage either due to condition instability or lack of care needs being met, which is a red flag for home care services to monitor and meet those needs appropriately. A Foley catheter requires home health care due to infection potential and care requirements. IV antibiotics also necessitate home care for maintaining line patency and assessing the site.

5. Signs of internal bleeding include all of the following except:

• A. painful or swollen extremities
• B. a tender, rigid abdomen
• C. vomiting bile
• D. bruising

Correct answer: C

Rationale: Vomiting bile is not typically a sign of internal bleeding but is more commonly associated with issues in the gastrointestinal tract. Signs of internal bleeding include painful or swollen extremities, a tender, rigid abdomen, and bruising. Painful or swollen extremities can indicate bleeding from an extremity injury, a tender, rigid abdomen can signal abdominal bleeding, and bruising can result from blood vessel damage. Therefore, the correct answer is 'C: vomiting bile,' as it is not a typical sign of internal bleeding.

Similar Questions