Nursing Elites

1. The Rule of Nines is used to:

• A. determine the amount of the body surface that has been burned
• B. assess the level of oxygen saturation in a body that has been burned.
• C. determine the level of tissue damage that has occurred in a burn.
• D. None of the above.

Correct answer: A

Rationale: The Rule of Nines is used to assess the amount of body surface that has been burned. Most body areas are divided out based on 9%, with the exception of the genitalia, which is only 1%.

2. A triage nurse has four clients arrive in the emergency department within 15 minutes. Which client should the triage nurse send back to be seen first?

• A. A 2-month-old infant with a history of rolling off the bed and having a bulging fontanelle with crying
• B. A teenager who suffered singed facial hair while camping
• C. An elderly client with complaints of frequent liquid brown-colored stools
• D. A middle-aged client with intermittent pain behind the right scapula

Correct answer: B

Rationale: The correct answer is the teenager who suffered singed facial hair while camping. This client is in the greatest danger with a potential risk of respiratory distress. Singed facial hair indicates exposure to heat or fire in close range, which could have caused serious damage to the interior of the lungs. It's crucial to prioritize this client as the interior lining of the lungs has no nerve fibers, so swelling may not be immediately noticeable. The other choices, while concerning, do not present an immediate life-threatening situation. The infant's condition may be serious but does not pose an immediate danger of respiratory distress. The elderly client's symptoms could indicate gastrointestinal issues, which are important but not as urgent as potential respiratory compromise. The middle-aged client's pain behind the right scapula, while uncomfortable, does not indicate an acute life-threatening condition requiring immediate attention.

3. A nurse is caring for newborn infants in a nursery when a man enters the area to take his baby back to the room. The man does not have an identification bracelet, and the nurse does not recognize him. What is the next action of the nurse?

• A. Call security and ask them to escort the man out of the nursery
• B. Ask the man to wait and check the infant's chart
• C. Ask the man to return to his room and bring an identification band
• D. Allow the man to take the baby to his room

Correct answer: C

Rationale: The safety of infants in newborn nurseries is maintained by requiring parents to wear identification bracelets to identify themselves as the rightful parents. This practice minimizes the risk of mistakenly allowing an unauthorized individual to take a baby. In this scenario, since the nurse does not recognize the man and he lacks an identification bracelet, the appropriate action is to ask him to return to his room and bring the identification band. This step ensures the proper identity verification before allowing the man to take the baby. Calling security without first verifying the man's identity may escalate the situation unnecessarily. Checking the infant's chart alone does not confirm the man's identity. Allowing the man to take the baby without proper verification poses a safety risk to the infant.

4. The nurse is preparing to perform a physical assessment. The correct action by the nurse is reflected by which statement?

• A. Performs the examination from both sides of the bed.
• B. Examines tender or painful areas last to help relieve the patient's anxiety.
• C. Follows a flexible examination sequence, considering the patient's age and condition.
• D. Organizes the assessment to ensure that the patient does not change positions too often.

Correct answer: D

Rationale: The nurse should organize the assessment to minimize the patient's need to change positions frequently, ensuring efficiency and comfort. It is essential to perform the examination from both sides of the bed to facilitate a comprehensive assessment. Examining tender or painful areas last can help reduce patient discomfort and anxiety. The examination sequence should be flexible, taking into account the patient's age, condition, and specific needs. This approach allows for a tailored and patient-centered assessment, optimizing the quality of care provided.

5. Which principle of body mechanics may help to reduce the risk of a back injury?

• A. Maintain a wide base of support
• B. Bend from the knees, not the waist
• C. Keep the back straight while lifting
• D. Push or pull objects rather than lifting

Correct answer: C

Rationale: Proper body mechanics are crucial to prevent injuries, especially for professions involving lifting and moving objects. Keeping the back straight while lifting is essential to reduce the risk of back injuries as it helps maintain the spine's natural alignment and prevents excessive strain on the back muscles. Choosing choices A, B, and D would increase the risk of back injury. Maintaining a wide base of support provides stability, bending from the knees instead of the waist protects the lower back, and pushing or pulling objects reduces the strain on the back muscles, all contributing to preventing back injuries.

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