Nursing Elites

1. After admission, which observation is most important for the nurse to report immediately for an adult client who weighs 150 pounds and has partial-thickness and full-thickness burns over 40% of the body from a house fire?

• A. Poor appetite and refusal to eat
• B. Systolic blood pressure at 102
• C. Painful moaning and crying
• D. Urinary output of 20 ml/hr

Correct answer: D

Rationale: A urinary output of 20 ml/hr is a sign of inadequate kidney perfusion and could indicate hypovolemic shock, which requires immediate intervention. In this situation, with severe burns over a large portion of the body, monitoring urinary output is crucial to assess kidney function and fluid status. Poor appetite, systolic blood pressure at 102, and painful moaning and crying are important but do not indicate the immediate need for intervention like inadequate urinary output does.

2. You are caring for a patient who just gave birth to a 6 lb. 13 oz. baby boy. The infant gave out a lusty cry, had a pink coloration all over his body, had flexed arms and legs, cried when stimulated, and had a pulse rate of 94. What Apgar score would you expect for this baby?

• A. 10
• B. 8
• C. 7
• D. 9

Correct answer: D

Rationale: The Apgar score is a method used to quickly assess the health of newborns. In this scenario, the baby would receive 2 points for color, reflex irritability, and muscle tone, but only 1 point for a pulse rate of 94, resulting in an Apgar score of 9. An Apgar score of 9 indicates that the baby is in good health overall. Choice A (10) is incorrect because a pulse rate of 94 would only score 1 point. Choices B (8) and C (7) are incorrect as the given criteria would lead to a higher score, indicating the baby's good health.

3. The single mother of a child with a head injury is sitting at the child's bedside crying when the PN enters the room. The mother states, 'Why did this happen to my child? I just can't cope with this.' How should the PN respond?

• A. Ask her to share how the injury occurred to her child.
• B. Recommend that she remain calm and positive for her child.
• C. Express that the present situation must be overwhelming.
• D. Determine if someone else can help her cope with this tragedy.

Correct answer: C

Rationale: Expressing empathy and acknowledging the mother's feelings helps in providing emotional support during a difficult time. This response validates her emotions and offers a comforting presence. Choice A is not appropriate as it focuses on gathering information rather than addressing the mother's emotional distress. Choice B may come off as dismissive of the mother's feelings and oversimplifies the complexity of the situation. Choice D shifts the responsibility to someone else instead of offering immediate support and comfort.

4. Thirty minutes after receiving IV morphine, a postoperative client continues to rate pain as 7 on a 10-point scale. Which action should the PN implement first?

• A. Call healthcare provider to request a different analgesic
• B. Determine when morphine can be given again
• C. Implement complementary pain relief methods
• D. Observe dressing to determine the presence of bleeding

Correct answer: C

Rationale: The most appropriate action for the PN to implement first is to implement complementary pain relief methods. This includes repositioning the client, applying heat or cold packs, or using relaxation techniques. These strategies can provide additional pain relief before the next dose of medication is due or before seeking further instructions from the healthcare provider. Calling the healthcare provider immediately to request a different analgesic (Choice A) may not be necessary at this moment since other non-pharmacological methods can be attempted first. Determining when morphine can be given again (Choice B) is important but addressing the client's immediate pain relief takes precedence. Observing the dressing for bleeding (Choice D) is important but not the first priority when the client is experiencing unrelieved pain.

5. Which statement by a mature adult client with advanced prostate cancer best indicates that he has reached a level of acceptance of his prognosis?

• A. I don't have any use for those who say the disease is going to win
• B. I've found the support I need from my faith and family
• C. I think I've had this disease for a long time, but the doctor did not find it
• D. I understand that this is a disease that occurs mostly in older men

Correct answer: B

Rationale: The correct answer is B because finding support in faith and family is a common way for individuals to cope with serious illnesses and come to terms with their prognosis. This statement indicates that the client has found a source of strength and comfort to deal with their situation. Choice A reflects defiance rather than acceptance. Choice C suggests denial or disbelief in the diagnosis. Choice D shows factual knowledge about the disease but does not necessarily indicate acceptance of the prognosis.

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