Nursing Elites

1. The nurse is performing triage on a group of clients in the emergency department. Which of the following clients should the nurse see first?

• A. A 12-year-old oozing blood from a laceration on the left thumb due to a cut from a rusty metal can
• B. A 19-year-old with a fever of 103.8°F who is able to identify her sister but not the place and time
• C. A 49-year-old with a compound fracture of the right leg who is complaining of severe pain
• D. A 65-year-old with a flushed face, dry mucous membranes, and a blood sugar of 470 mg/dL

Correct answer: B

Rationale: The correct answer is B. A 19-year-old with a fever of 103.8°F who is confused and unable to orient to place and time likely has a severe infection or a serious medical condition affecting the central nervous system. This client needs immediate attention as altered mental status combined with a high fever can indicate a life-threatening situation. Choices A, C, and D present important conditions that require medical care, but they are not as urgent as the 19-year-old with a high fever and confusion. The 12-year-old with a laceration may require treatment for bleeding and a tetanus shot, the 49-year-old with a compound fracture needs urgent orthopedic intervention, and the 65-year-old with a high blood sugar is concerning for hyperglycemia but can wait momentarily compared to the client with a fever and altered mental status.

2. A nurse is maintaining droplet precautions for a client who has meningitis. Which of the following actions should the nurse take?

• A. Wear a gown within 3 feet of the client
• B. Maintain a distance of 6 feet from the client
• C. Wear a surgical mask within 3 feet of the client
• D. Remove gloves before leaving the room

Correct answer: C

Rationale: The correct action for the nurse to take when maintaining droplet precautions for a client with meningitis is to wear a surgical mask within 3 feet of the client. This is essential to prevent the transmission of meningitis via respiratory droplets. Choice A is incorrect because wearing a gown is not specifically required for droplet precautions. Choice B suggests maintaining a distance of 6 feet, which is more applicable to airborne precautions, not droplet precautions. Choice D is incorrect as gloves should be removed and disposed of properly, but it is not related to droplet precautions specifically.

3. A client has a prescription for nitroglycerin sublingual tablets. Which of the following instructions should the nurse include in the teaching?

• A. Place the tablet under the tongue and wait 10 minutes
• B. Take up to five tablets during an angina episode
• C. Take up to three tablets during a single angina episode
• D. Swallow the tablet with water

Correct answer: C

Rationale: The correct answer is C: 'Take up to three tablets during a single angina episode.' Nitroglycerin can be taken up to three times during an episode to relieve angina. Choice A is incorrect because the client should place the tablet under the tongue and wait for it to dissolve, not wait for 10 minutes. Choice B is incorrect because taking up to five tablets during an angina episode is excessive and not recommended. Choice D is incorrect because nitroglycerin tablets are meant to be taken sublingually, not swallowed.

4. A client who is postoperative following a cholecystectomy has a urine output of 25 mL/hr. Which of the following findings should the nurse report to the provider?

• A. Abdominal pain radiating to the right shoulder.
• B. Absent bowel sounds.
• C. Brown drainage on the surgical dressing.
• D. Urine output of 25 mL/hr.

Correct answer: D

Rationale: A urine output below 30 mL/hr indicates a potential complication, such as hypovolemia or renal impairment, and should be reported. Abdominal pain radiating to the right shoulder can be common after a cholecystectomy due to referred pain from the diaphragm, whereas absent bowel sounds may be expected temporarily postoperatively. Brown drainage on the surgical dressing is typical in the early postoperative period and may represent old blood or other normal discharge.

5. Which of the following situations can be identified as an ethical dilemma?

• A. A nurse demonstrates signs of chemical impairment
• B. A family has conflicting feelings about tube feeding for their terminally ill father
• C. A nurse overhears a colleague threatening to restrain a patient if they do not stay in bed
• D. A client with terminal cancer hesitates to name their spouse as power of attorney

Correct answer: B

Rationale: The correct answer is B. Ethical dilemmas involve conflicting values or feelings. In this situation, the family is conflicted about tube feeding for their terminally ill father, which presents a moral and ethical challenge. Choices A, C, and D do not represent ethical dilemmas. Choice A involves a nurse's impairment, which is a different issue. Choice C involves a nurse's observation of a colleague's threat, which is a patient safety concern. Choice D involves a client's hesitation in naming a spouse as power of attorney, which is a legal and decision-making issue, not necessarily an ethical dilemma.

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