Nursing Elites

1. In a disaster area, a nurse assesses an adult male with partial-thickness burns on his lower legs, approximately 10% of his lower body. Which color of triage tag should the nurse place on this client?

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

Correct answer: A

Rationale: A yellow triage tag should be placed on the client with partial-thickness burns covering 10% of his lower body. Yellow tags indicate delayed treatment, suitable for serious injuries that are not immediately life-threatening. Black tags are used for deceased individuals, red tags for immediate treatment of life-threatening injuries, and green tags for minor injuries.

2. A client with deep vein thrombosis (DVT) is receiving heparin therapy. Which laboratory test should the nurse monitor to evaluate the effectiveness of the heparin?

• A. Complete blood count (CBC)
• B. Activated partial thromboplastin time (aPTT)
• C. Prothrombin time (PT)
• D. International normalized ratio (INR)

Correct answer: B

Rationale: The correct answer is B: Activated partial thromboplastin time (aPTT). This test is used to monitor the effectiveness of heparin therapy. A complete blood count (CBC) (choice A) is not specific for monitoring heparin therapy. Prothrombin time (PT) (choice C) and International normalized ratio (INR) (choice D) are more commonly used to monitor warfarin therapy, not heparin.

3. A postoperative client reports incisional pain. The client has two prescriptions for PRN analgesia that accompanied the client from the post-anesthesia unit. Before selecting which medication to administer, which action should the nurse implement?

• A. Document the client's report of pain in the electronic medical record.
• B. Determine which prescription will have the quickest onset of action.
• C. Compare the client's pain scale rating with the prescribed dosing.
• D. Ask the client to choose which medication is needed for the pain.

Correct answer: C

Rationale: The correct action the nurse should implement before selecting which medication to administer to a postoperative client who reports incisional pain is to compare the client's pain scale rating with the prescribed dosing. This ensures that the client receives the appropriate medication based on their pain level. Documenting the client's report of pain in the electronic medical record (Choice A) is important but should come after ensuring the right medication is given. Determining which prescription will have the quickest onset of action (Choice B) may not be the most relevant factor to consider when choosing the appropriate medication. Asking the client to choose the medication needed for the pain (Choice D) may not be appropriate as the nurse should rely on the pain scale rating and prescribed dosing to make a clinical decision.

4. What is a priority action for the nurse when caring for a client with suspected meningitis?

• A. Isolate the client in a private room
• B. Administer intravenous antibiotics
• C. Obtain a throat culture
• D. Perform a chest x-ray

Correct answer: B

Rationale: Administering intravenous antibiotics is the priority when caring for a client with suspected meningitis. The prompt administration of antibiotics is crucial to treat bacterial meningitis and prevent potential complications. Isolating the client in a private room may be necessary to prevent the spread of infection, but antibiotic administration takes precedence. Obtaining a throat culture and performing a chest x-ray are important diagnostic measures, but they do not address the immediate need for antibiotic therapy in suspected bacterial meningitis.

5. An older client is receiving an IV of 5% dextrose in 0.45% normal saline at 75 mL/hour. Which assessment finding indicates to the nurse that the client is developing a complication from this therapy?

• A. Capillary refill takes > 3 seconds.
• B. Episodes of vertigo and loss of balance.
• C. Average daily output of 1200 ml.
• D. Pulse rate of 110 beats/minute and dyspnea upon exertion.

Correct answer: D

Rationale: The correct answer is D. Tachycardia and dyspnea are signs of fluid overload, which is a potential complication of IV fluid therapy. Choices A, B, and C are not directly related to fluid overload and are not typical signs of complications associated with the IV fluid therapy being administered.

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