Nursing Elites

1. An adult male is brought to the emergency department following a motorcycle accident, presenting with periorbital bruising and bloody drainage from both ears. Which assessment finding warrants immediate intervention by the nurse?

• A. Rebound abdominal tenderness.
• B. Diminished bilateral breath sounds.
• C. Rib pain with deep inspiration.
• D. Nausea with projectile vomiting.

Correct answer: D

Rationale: In this scenario, the patient's presentation with periorbital bruising and bloody ear drainage suggests a basilar skull fracture. Projectile vomiting, as described in choice D, is concerning for increased intracranial pressure due to the skull fracture. This finding warrants immediate intervention to prevent further neurological compromise. Choices A, B, and C are not the priority in this situation. Rebound abdominal tenderness (choice A) is indicative of intra-abdominal injury but is not as urgent as managing potential intracranial issues. Diminished breath sounds (choice B) and rib pain with deep inspiration (choice C) may suggest underlying chest injuries, which need attention but are not as immediately life-threatening as increased intracranial pressure.

2. The nurse is teaching a client about postoperative care following a total knee arthroplasty. What instruction should the nurse prioritize?

• A. Begin ambulation as soon as possible.
• B. Use continuous passive motion therapy to maintain joint mobility.
• C. Avoid putting weight on the affected leg.
• D. Apply ice packs to reduce pain and swelling.

Correct answer: B

Rationale: The correct answer is B: 'Use continuous passive motion therapy to maintain joint mobility.' Continuous passive motion therapy is crucial in postoperative care following a total knee arthroplasty as it helps prevent stiffness and maintain joint mobility. Ambulation is important but should be guided and not immediate. Avoiding putting weight on the affected leg is also essential initially to prevent complications. Applying ice packs can help reduce pain and swelling, but it is not the priority instruction for maintaining joint mobility and preventing stiffness.

3. A client frequently admitted to the locked psychiatric unit repeatedly compliments and invites one of the nurses to go out on a date. The nurse's response should be to

• A. Ask not to be assigned to this client or to work on another unit
• B. Tell the client that such behavior is inappropriate
• C. Inform the client that hospital policy prohibits staff from dating clients
• D. Discuss the boundaries of the therapeutic relationship with the client

Correct answer: D

Rationale: The correct response for the nurse in this situation is to discuss the boundaries of the therapeutic relationship with the client. By doing so, the nurse can reinforce professionalism, establish clear boundaries, and prevent ethical conflicts. Option A is incorrect because avoiding the client or unit does not address the issue at hand and may compromise patient care. Option B, while acknowledging the behavior, does not address the underlying reasons and boundaries. Option C, stating hospital policy, is not as therapeutic or client-centered as discussing the therapeutic relationship directly.

4. A male client with a history of deep vein thrombosis (DVT) is admitted with new onset shortness of breath and a productive cough. What is the nurse's priority action?

• A. Administer prescribed anticoagulant.
• B. Notify the healthcare provider.
• C. Auscultate lung sounds.
• D. Prepare for chest physiotherapy.

Correct answer: A

Rationale: Administering an anticoagulant is the nurse's priority action in this situation. Given the client's history of DVT and the presentation of new onset shortness of breath and a productive cough, there is a concern for a pulmonary embolism, which is a life-threatening complication of DVT. Administering an anticoagulant promptly is crucial to prevent further clot formation and to manage the existing clot, reducing the risk of pulmonary embolism. While auscultating lung sounds and preparing for chest physiotherapy are important actions in respiratory assessment and management, the priority in this case is to address the potential complication of a pulmonary embolism by administering the anticoagulant. Notifying the healthcare provider can be done after initiating the immediate intervention of anticoagulant therapy.

5. The healthcare provider is caring for a client with severe anemia. Which assessment finding requires immediate intervention?

• A. Pale skin
• B. Increased heart rate
• C. Shortness of breath
• D. Fatigue

Correct answer: C

Rationale: Shortness of breath is a critical sign in severe anemia as it indicates inadequate oxygenation, which can be life-threatening. Immediate intervention is necessary to address this condition. Pale skin (choice A) is a common finding in anemia but not as urgent as shortness of breath. Increased heart rate (choice B) is a compensatory mechanism in anemia to maintain oxygen delivery and is important but not as urgent as addressing inadequate oxygenation. Fatigue (choice D) is a common symptom in anemia but does not indicate an immediate life-threatening situation like shortness of breath does.

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