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. When prioritizing client care after receiving change-of-shift report, which of the following clients should the nurse plan to see first?

• A. A client who is scheduled for an abdominal x-ray and is awaiting transport
• B. A client who has a prescription for discharge
• C. A client who received oral pain medication 30 minutes ago
• D. A client who told an assistive personnel he is short of breath

Correct answer: D

Rationale: When a client expresses being short of breath, it may indicate a serious condition requiring immediate attention to ensure adequate oxygenation. This client should be seen first to assess the severity of the situation and initiate appropriate interventions. The other options, such as awaiting transport for an x-ray, having a prescription for discharge, or receiving oral pain medication 30 minutes ago, do not present immediate life-threatening concerns compared to a client experiencing shortness of breath.

3. When orienting a new client and family to the inpatient unit, what information should the nurse provide to help the client promote their own safety?

• A. Encourage the client and family to be active partners.
• B. Instruct the client to monitor hand hygiene in caregivers.
• C. Offer the family the opportunity to stay with the client.
• D. Advise the client to always wear their armband.

Correct answer: A

Rationale: Encouraging the client and family to be active partners in their healthcare is crucial for promoting safety. When clients and families actively participate, they are more likely to advocate for themselves, ask questions, and be engaged in their care, leading to better outcomes and reduced risks.

4. While caring for a client receiving positive-pressure mechanical ventilation, which intervention should the nurse NOT implement to prevent complications?

• A. Elevate the head of the bed to at least 30°.
• B. Verify the prescribed ventilator settings daily.
• C. Administer pantoprazole as prescribed.
• D. Reposition the endotracheal tube to the opposite side of the mouth daily.

Correct answer: D

Rationale: Repositioning the endotracheal tube to the opposite side of the mouth daily is not a standard practice and can increase the risk of complications, such as accidental extubation or damage to the airway. The endotracheal tube should remain in the initial correct position to ensure proper ventilation and prevent harm to the client. Elevating the head of the bed, verifying ventilator settings, and administering pantoprazole as prescribed are all appropriate interventions to prevent complications in a client receiving positive-pressure mechanical ventilation.

5. A healthcare professional is assessing a client who has a fracture of the femur. Vital signs are obtained on admission and again in 2 hours. Which of the following changes in assessment should indicate to the healthcare professional that the client could be developing a serious complication?

• A. Increased respiratory rate from 18 to 44/min
• B. Increased oral temperature from 36.6° C (97.8° F) to 37° C (98.6° F)
• C. Increased blood pressure from 112/68 to 120/72 mm Hg
• D. Increased heart rate from 68 to 72/min

Correct answer: A

Rationale: An increased respiratory rate from 18 to 44/min is a significant change that should alert the healthcare professional to a potential serious complication. Such a drastic increase in respiratory rate may indicate respiratory distress or hypoxia, which are critical conditions requiring immediate attention. The other options show minor changes in vital signs that are within normal limits and are less likely to indicate a serious complication.

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