Nursing Elites

1. After a spider bite on the lower extremity, a client is admitted to treat an infection that is spreading up the leg. Which admission assessment findings should the nurse report to the healthcare provider?

• A. Swollen lymph nodes in the groin
• B. Core body temperature of 100.5°F
• C. All of the above
• D. Elevated white blood cell count

Correct answer: C

Rationale: All of the above findings should be reported to the healthcare provider for prompt evaluation and treatment. Swollen lymph nodes in the groin indicate regional lymphatic involvement, a core body temperature of 100.5°F suggests a mild fever response, and an elevated white blood cell count indicates an ongoing infection process. These findings collectively point towards the spread of infection and require immediate attention to prevent further complications.

2. While assessing an older client's fall risk, the client reports living at home alone and never falling. Which action should the nurse take?

• A. Suggest moving to an assisted living facility
• B. Continue to obtain client data needed to complete the fall risk survey
• C. Reduce the frequency of fall risk assessments for this client
• D. Confirm that the client is safe living alone

Correct answer: B

Rationale: The correct action for the nurse to take is to continue obtaining client data to complete the fall risk survey. Even though the client reports never falling, it is essential to assess all fall risk factors comprehensively. Fall risk surveys provide valuable information on mobility, vision, medications, and other factors that can impact safety. Option A is incorrect because suggesting moving to an assisted living facility is premature without completing the fall risk assessment. Option C is incorrect as reducing the frequency of fall risk assessments could overlook potential risk factors. Option D is incorrect as the client's statement alone is not enough to confirm their safety living alone; a thorough assessment is necessary.

3. A client with dyspnea is being admitted to the medical unit. To best prepare for the client's arrival, the nurse should ensure that the client's bed is in which position?

• A. Trendelenburg
• B. Supine
• C. Prone
• D. Fowler's

Correct answer: D

Rationale: Fowler's position (head elevated at 45-60 degrees) improves oxygenation by expanding the lungs, making it the best position for clients with dyspnea. Supine or prone positions restrict lung expansion, and Trendelenburg position (head down) can exacerbate breathing difficulties by increasing pressure on the lungs and diaphragm.

4. A client is admitted with a suspected gastrointestinal bleed. What assessment finding requires immediate intervention?

• A. Bright red blood in the vomit.
• B. Elevated blood pressure and heart rate.
• C. Coffee ground emesis.
• D. Dark, tarry stools.

Correct answer: D

Rationale: Dark, tarry stools indicate the presence of digested blood in the gastrointestinal tract, signifying a higher gastrointestinal bleed. This finding requires immediate intervention due to the potential severity of the bleed. Bright red blood in the vomit may indicate active bleeding but is not as concerning as digested blood. Elevated blood pressure and heart rate are common responses to bleeding but do not provide direct evidence of the source or severity of the bleed. Coffee ground emesis is indicative of partially digested blood and is a concern but not as urgent as dark, tarry stools.

5. The healthcare worker is wearing PPE while caring for a client. When exiting the room, which PPE should be removed first?

• A. Gloves
• B. Face shield
• C. Mask
• D. Gown

Correct answer: A

Rationale: Gloves should be removed first as they are most likely to be contaminated. This is followed by the gown, then face shield, and mask. Correct removal sequence helps prevent contamination. Removing gloves first reduces the risk of transferring pathogens from the gloves to other PPE or surfaces. Face shield and mask should be removed last as they protect mucous membranes from exposure to contaminants. Removing PPE in the correct sequence is crucial in preventing the spread of infections.

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