Nursing Elites

1. After applying oxygen using bi-nasal prongs to a client who is having chest pain, the nurse should implement which intervention?

• A. Have the client take slow deep breaths in through their mouth and out through their nose.
• B. Post signs indicating that oxygen is in use on the client's door and in their room
• C. Apply Vaseline petroleum to both nares and 2 by 2 gauze around the oxygen tubing at the client's ears
• D. Encourage the client to hyperextend the neck, take a few deep breaths and cough.

Correct answer: A

Rationale: After applying oxygen using bi-nasal prongs to a client with chest pain, it is essential for the nurse to post signs indicating that oxygen is in use on the client's door and in their room. This safety precaution alerts healthcare providers and visitors that the client is receiving oxygen therapy, reducing the risk of accidents or misunderstandings. Choice A is incorrect because instructing the client to take slow deep breaths is not the appropriate intervention after applying oxygen. Choice C suggests applying Vaseline and gauze, which is unnecessary and not a standard practice. Choice D advising the client to hyperextend the neck, take deep breaths, and cough is not indicated after applying oxygen therapy and could potentially be harmful.

2. A healthcare professional is assessing a patient in the rehab unit during shift change. The patient has sustained a TBI 3 weeks ago. Which of the following is the most distinguishing characteristic of a neurological disturbance?

• A. LOC (level of consciousness)
• B. Short-term memory
• C. Babinski sign
• D. Clonus sign

Correct answer: A

Rationale: Level of consciousness (LOC) is the most crucial indicator of impaired neurological function. Changes in LOC can signify various neurological conditions, including traumatic brain injury. Short-term memory, while important, is not the most distinguishing characteristic of neurological disturbances. Babinski and Clonus signs are specific neurological tests that can provide information about upper motor neuron lesions but are not as generalizable as changes in LOC for assessing overall neurological status.

3. What is pica?

• A. dependency on alcohol
• B. increased iron in the diet
• C. the sickle cell trait
• D. eating ice

Correct answer: D

Rationale: Pica is a disorder characterized by the ingestion of nonfood substances, which can lead to a clinical iron deficiency. It may be the first sign of an underlying issue. Individuals with pica consume a variety of nonfood items such as ice, clay, dirt, or paste. Choice A, dependency on alcohol, is incorrect as it is not related to pica. Choice B, increased iron in the diet, is incorrect because pica involves ingesting nonfood items rather than having an increased intake of iron. Choice C, the sickle cell trait, is unrelated to pica and is therefore incorrect.

4. The client has jaundice, elevated liver enzymes, and an elevated serum bilirubin. What color urine does the nurse expect to find?

• A. Pink-tinged
• B. Straw-colored
• C. Clear
• D. Dark amber

Correct answer: D

Rationale: The correct answer is dark amber. In jaundice, the elevated bilirubin levels are excreted in the urine, giving it a dark amber color. Choices A, B, and C are incorrect because in jaundice, the urine typically appears dark amber due to the presence of elevated bilirubin, not pink-tinged, straw-colored, or clear.

5. The nurse is obtaining a health assessment from the preoperative client scheduled for hip replacement surgery. Which statement by the client would be most important for the nurse to report to the physician?

• A. "I had chickenpox when I was 8 years old."?
• B. "I had rheumatic fever when I was 10 years old."?
• C. "I have a strong family history of gastric cancer."?
• D. "I have pain in my hip with any movement."?

Correct answer: B

Rationale: The most important statement for the nurse to report to the physician is that the client had rheumatic fever when they were 10 years old. This information is crucial as individuals who have had rheumatic fever require pre-medication with antibiotics before any surgical or dental procedure to prevent bacterial endocarditis. Reporting this history ensures the client's safety during the hip replacement surgery. The other options, such as having chickenpox in the past, a family history of gastric cancer, or experiencing hip pain, are important for the client's overall health assessment but do not have the same immediate implications for the upcoming surgery as the history of rheumatic fever.

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