Nursing Elites

1. In which of the following organs does the exchange of gases take place?

• A. Kidneys
• B. Lungs
• C. Liver
• D. Heart

Correct answer: B

Rationale: The exchange of gases, specifically oxygen and carbon dioxide, occurs in the lungs. In the lungs, oxygen from the air we breathe enters the bloodstream, while carbon dioxide is removed from the bloodstream and exhaled. This process is essential for respiration and supplying the body with oxygen for energy production. The kidneys filter waste from the blood to produce urine and regulate fluid balance (Choice A). The liver is involved in detoxification, protein synthesis, and producing bile (Choice C). The heart is responsible for pumping blood throughout the body to deliver oxygen and nutrients (Choice D).

2. In the emergency department, a nurse is assessing a client involved in a motor vehicle crash. Findings include absent breath sounds in the left lower lobe with dyspnea, blood pressure 118/68 mm Hg, heart rate 124/min, respirations 38/min, temperature 38.6 C (101.4 F), and SaO2 92% on room air. What action should the nurse take first?

• A. Obtain a chest X-ray.
• B. Prepare for chest tube insertion.
• C. Administer oxygen via high-flow mask.
• D. Initiate IV access.

Correct answer: C

Rationale: In this scenario, the client is presenting with signs of respiratory distress, including absent breath sounds, dyspnea, and a low SaO2 level. The priority action should be to improve oxygenation by administering oxygen via a high-flow mask. This intervention aims to increase the oxygen supply to the client's lungs, helping to address the hypoxemia. Once oxygenation is optimized, further interventions, such as obtaining a chest X-ray, preparing for chest tube insertion, or initiating IV access, can be considered based on the client's condition and healthcare provider's orders.

3. A client has generalized petechiae and ecchymoses. The nurse should expect a prescription for which of the following laboratory tests?

• A. Platelet count
• B. Potassium level
• C. Creatinine clearance
• D. Prealbumin

Correct answer: A

Rationale: Generalized petechiae and ecchymoses can indicate a potential issue with platelet function or count. Therefore, the most relevant laboratory test to evaluate this condition would be a platelet count. Platelet count helps assess the number of platelets in the blood, which are crucial for clotting and preventing bleeding. Monitoring platelet levels can provide important information about a client's bleeding risk and overall hematologic health.

4. Which of the following interventions is considered the most effective form of universal precautions?

• A. Cap all used needles before removing them from their syringes
• B. Discard all used uncapped needles and syringes in an impenetrable protective container
• C. Wear gloves when administering IM injections
• D. Follow enteric precautions

Correct answer: B

Rationale: The most effective form of universal precautions is to discard all used uncapped needles and syringes in an impenetrable protective container. This practice minimizes the risk of needle-stick injuries, which are a significant concern when dealing with used needles. By safely disposing of uncapped needles, healthcare providers can protect themselves and others from potential exposure to bloodborne pathogens.

5. A charge nurse is recommending postpartum client discharge following a local disaster. Which of the following should the nurse recommend for discharge?

• A. A 42-year-old client who has preeclampsia and a BP of 166/110 mm Hg
• B. A 15-year-old client who delivered via emergency cesarean birth 1 day ago
• C. A client who received 2 units of packed RBCs 6 hr ago for a postpartum hemorrhage
• D. A client who delivered precipitously 36 hr ago and has a second-degree perineal laceration

Correct answer: D

Rationale: The most appropriate client to recommend for discharge following a local disaster in the postpartum unit is the one who delivered precipitously 36 hours ago and has a second-degree perineal laceration. This client's condition is stable enough for discharge, and the timing and extent of the perineal laceration are within expectations for a safe discharge. Clients with conditions such as preeclampsia, recent emergency cesarean birth, or recent administration of packed RBCs for postpartum hemorrhage require further monitoring and care before being considered for discharge.

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