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 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.

3. A male client admitted three days ago with respiratory failure is intubated, and 40% oxygen per facemask is initiated. Currently, his temperature is 99°F, capillary refill is less than 4 seconds, and respiratory effort is within normal limits. What outcome should the nurse evaluate to measure for successful extubation?

• A. Exhibits adequate tissue perfusion
• B. Remains free of injury
• C. Remains free of infection
• D. Maintains effective breathing pattern

Correct answer: D

Rationale: Successful extubation relies on the patient's ability to maintain an effective breathing pattern. This indicates that the patient can adequately oxygenate and ventilate without the need for mechanical support. Monitoring tissue perfusion, preventing infection, and ensuring safety are important but not directly related to the immediate criteria for successful extubation. Tissue perfusion, injury prevention, and infection control are crucial aspects of overall patient care but are not the primary factors to consider when evaluating readiness for extubation.

4. A client with diabetes mellitus reports feeling dizzy and has a blood glucose level of 50 mg/dl. What action should the nurse take first?

• A. Administer 1 mg of glucagon intramuscularly
• B. Provide 15 grams of carbohydrate
• C. Check the client's blood pressure
• D. Notify the healthcare provider

Correct answer: B

Rationale: Providing 15 grams of carbohydrate is the initial action to treat hypoglycemia. When a client with diabetes mellitus experiences symptoms of hypoglycemia, such as dizziness and with a blood glucose level of 50 mg/dl, the immediate priority is to raise their blood sugar levels quickly. Administering carbohydrates, such as fruit juice or glucose tablets, is the recommended first step to reverse hypoglycemia. Administering glucagon intramuscularly is usually reserved for severe hypoglycemia when the client is unconscious or unable to swallow. Checking the client's blood pressure is important but not the primary intervention for hypoglycemia. Notifying the healthcare provider can be done after the immediate management of hypoglycemia.

5. A nurse is planning care for a client who is at risk for developing deep vein thrombosis (DVT). Which intervention should the nurse include in this client's plan of care?

• A. Maintain the client on bed rest
• B. Apply warm, moist compresses to the legs
• C. Encourage early ambulation
• D. Massage the legs daily

Correct answer: C

Rationale: The correct intervention for a client at risk for developing deep vein thrombosis (DVT) is to encourage early ambulation. Early ambulation helps prevent DVT by promoting circulation, reducing stasis, and preventing blood clot formation. Maintaining the client on bed rest (Choice A) would increase the risk of DVT due to decreased mobility. Applying warm, moist compresses to the legs (Choice B) can be beneficial for other conditions but does not directly prevent DVT. Massaging the legs daily (Choice D) can dislodge a blood clot, leading to serious complications in a client at risk for DVT.

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