Nursing Elites

1. The trauma unit nurse has received a report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first?

• A. Evaluate chest expansion.
• B. Check pupillary response to light.
• C. Assess the capillary refill.
• D. Check the client's response to questions about place and time.

Correct answer: A

Rationale: In a client with multiple injuries following a motor vehicle crash, the priority is to assess for any compromised airway or breathing. Evaluating chest expansion helps the nurse determine if the client is having any difficulty breathing, which is essential for immediate intervention to maintain adequate oxygenation. Checking pupillary response, assessing capillary refill, and checking the client's orientation to place and time are important assessments but are of lower priority compared to ensuring the client's airway and breathing are intact.

2. A client has burns to his face, ears, and eyelids. What is the priority finding for the nurse to report to the provider?

• A. Urinary output of 25 mL/hr
• B. Difficulty swallowing
• C. Heart rate of 122/min
• D. Pain level of 6 on a scale of 0 to 10

Correct answer: B

Rationale: When a client has burns involving the face, ears, and eyelids, the priority finding to report to the provider is difficulty swallowing. This symptom could indicate potential airway compromise or swelling in the throat, which can lead to serious complications. Monitoring and addressing this issue promptly is crucial to ensure the client's airway remains patent and secure.

3. A client who is interested in smoking cessation receives teaching from a nurse. Which statements should the nurse include in this teaching? (Select ONE that does not apply)

• A. Find an activity that you enjoy and that will keep your hands busy.
• B. Keep healthy snacks on hand to nibble on.
• C. Identify reasons for quitting smoking.
• D. Make a list of reasons for quitting smoking.

Correct answer: C

Rationale: When teaching a client interested in smoking cessation, the nurse should include advice to find an activity that keeps hands busy to help distract from smoking urges, keep healthy snacks on hand to manage oral cravings, and drink at least 8 glasses of water daily to aid in flushing out toxins. Making a list of reasons for quitting smoking is also beneficial to reinforce motivation. It is important to avoid punitive measures or punishments for relapses as this can negatively impact the client's progress.

4. A client underwent a total laryngectomy. Which of the following is the priority observation in the client's care?

• A. Patency of the intravenous line
• B. Level of pain
• C. Integrity of the dressing
• D. Need for suctioning

Correct answer: D

Rationale: Following a total laryngectomy, maintaining a clear airway is crucial to prevent complications such as airway obstruction due to secretions or blood clots. Monitoring the need for suctioning takes precedence to ensure the client's airway remains patent. While monitoring pain levels, IV line patency, and dressing integrity are important aspects of care, ensuring adequate airway clearance through suctioning is the priority in this scenario.

5. A client with a pleural effusion is being assessed by a nurse. Which clinical manifestation does the nurse expect to find?

• A. Decreased breath sounds on the affected side
• B. Hyperresonance on percussion of the affected side
• C. Increased tactile fremitus on the affected side
• D. Tracheal deviation toward the affected side

Correct answer: A

Rationale: In a client with pleural effusion, decreased breath sounds on the affected side are common due to the presence of fluid in the pleural space. Hyperresonance is not expected; dullness on percussion is more likely. Tactile fremitus is typically decreased, not increased, in pleural effusion cases. Tracheal deviation away from the affected side, not toward it, can be seen with large effusions.

Similar Questions