Nursing Elites

1. The nurse is triaging clients from a train wreck. A client has multiple open wounds, a blood pressure of 90/56, and a pulse of 112 beats/minute. Which triage tag color should the nurse place on this client?

• A. Black
• B. Yellow
• C. Green
• D. Red

Correct answer: D

Rationale: The correct answer is D: Red. The client's vital signs indicate critical condition with a high pulse and low blood pressure, suggesting shock. A red tag is used to identify patients who require immediate attention and should be prioritized for treatment. Choice A, Black, is incorrect as it is typically used for deceased or expectant clients. Choice B, Yellow, is used for clients with non-life-threatening injuries who require medical care but can wait. Choice C, Green, is for clients with minor injuries who can wait the longest for treatment. Therefore, in this scenario, the client's condition warrants a red triage tag for immediate attention.

2. A client who is 12-hours post-op following a left hip replacement has an indwelling urinary catheter. The nurse determines that the client's urinary output is 60 ml in the past 3 hours. What action should the nurse take first?

• A. Assess the client's vital signs
• B. Irrigate the catheter with 30 ml of sterile normal saline
• C. Notify the healthcare provider
• D. Replace the catheter with a larger size

Correct answer: A

Rationale: In a client post-op with low urinary output, the first action the nurse should take is to assess the client's vital signs. Vital signs can provide valuable information about the client's overall condition, fluid status, and potential complications. Assessing the vital signs can help the nurse to determine if the low urine output is indicative of a larger issue that needs immediate attention. Irrigating the catheter with normal saline may be necessary but should not be the first action without assessing the client. Notifying the healthcare provider should follow assessment if there are concerns. Replacing the catheter with a larger size is not indicated solely based on low urinary output and should not be the first action taken.

3. A client who is HIV positive and taking lamivudine (Epivir) calls the clinic to report a cough and fever. What action should the nurse implement?

• A. Advise the client to come to the clinic for an evaluation
• B. Advise the client to increase fluid intake
• C. Advise the client to take an over-the-counter cough suppressant
• D. Advise the client to rest and call if the fever persists

Correct answer: A

Rationale: The correct action for the nurse to implement in this situation is to advise the client to come to the clinic for an evaluation. Given the client's HIV-positive status and medication, it is crucial to assess the cough and fever promptly to identify the underlying cause. Increasing fluid intake (choice B) may be beneficial but does not address the need for evaluation. Taking an over-the-counter cough suppressant (choice C) may not be appropriate without knowing the cause of the symptoms. Advising the client to rest and call if the fever persists (choice D) delays the necessary evaluation and treatment.

4. A nurse is caring for a client with a new colostomy. Which instruction should the nurse include in the client's teaching plan?

• A. Change the ostomy appliance daily
• B. Empty the ostomy pouch when it is one-third full
• C. Rinse the ostomy pouch with warm water
• D. Apply a skin barrier to the peristomal skin

Correct answer: B

Rationale: The correct instruction the nurse should include in the client's teaching plan is to empty the ostomy pouch when it is one-third full. This practice helps prevent leakage and skin irritation by maintaining an appropriate pouching system. Changing the ostomy appliance daily (Choice A) is not necessary unless leakage or other issues occur. Rinsing the ostomy pouch with warm water (Choice C) is not a recommended practice as it may cause damage to the pouch. Applying a skin barrier to the peristomal skin (Choice D) is important but not the most crucial instruction in this scenario.

5. A nurse is planning care for a client who is newly diagnosed with diabetes mellitus. Which instruction should the nurse include in this client’s teaching plan?

• A. Avoid all forms of sugar
• B. Check blood glucose levels once a week
• C. Rotate insulin injection sites
• D. Monitor urine ketone levels

Correct answer: C

Rationale: Rotating insulin injection sites prevents lipodystrophy and ensures proper insulin absorption.

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