Nursing Elites

1. Where do the vast majority of deaths resulting from unintentional poisoning occur?

• A. Infants
• B. Toddlers
• C. Teens
• D. Adults

Correct answer: B

Rationale: The correct answer is 'Toddlers.' Toddlers are at the highest risk of unintentional poisoning due to their natural curiosity, explorative behavior, and lack of awareness of potential dangers. Infants are typically closely monitored, teens are more aware of risks, and adults generally have better judgment and understanding of hazardous substances, making them less susceptible to unintentional poisoning. Therefore, toddlers, being inquisitive and unaware of risks, are the most vulnerable group in terms of unintentional poisoning incidents.

2. Mrs. Peterson complains of difficulty falling asleep, awakening earlier than desired, and not feeling rested. She attributes these problems to leg pain that is secondary to her arthritis. What is the most appropriate nursing diagnosis for her?

• A. Sleep Pattern Disturbances (related to chronic leg pain)
• B. Fatigue (related to leg pain)
• C. Knowledge Deficit (regarding sleep hygiene measures)
• D. Sleep Pattern Disturbances (related to chronic leg pain)

Correct answer: D

Rationale: The most appropriate nursing diagnosis for Mrs. Peterson is 'Sleep Pattern Disturbances (related to chronic leg pain).' Mrs. Peterson's sleep issues are directly linked to her chronic leg pain, which is a result of her arthritis. This nursing diagnosis addresses the primary cause of her sleep disturbances and allows for interventions that focus on managing the pain to improve her sleep. Choices A, B, and C are incorrect. Choice A correctly identifies the relationship between sleep disturbances and chronic leg pain, addressing the root cause. Choice B is incorrect as it only focuses on fatigue and does not encompass the broader sleep issues. Choice C is not relevant as there is no indication that Mrs. Peterson lacks knowledge about sleep hygiene measures.

3. All of the following tasks could be delegated to a nursing assistant or unlicensed assistive personnel (UAP) except:

• A. monitoring intravenous infusion
• B. assisting a client to the bathroom
• C. offering fluid intake every 1-2 hours
• D. monitoring/recording the amount of fluid taken

Correct answer: A

Rationale: Monitoring an intravenous infusion involves assessing for complications, adjusting the flow rate, and monitoring the client's response, which requires the knowledge and skills of a licensed nurse (RN or LPN). Tasks that can be delegated to nursing assistants or unlicensed assistive personnel include assisting a client to the bathroom, offering fluids, and recording fluid intake. These activities are within the scope of practice for UAPs as they do not involve the specialized knowledge and training needed for intravenous infusion monitoring.

4. The nurse receives an assignment of three clients. Which of the following should the nurse consider as the highest priority when determining which client to assess first?

• A. the client who most recently rang their call bell
• B. the client who has been waiting the longest for their call bell to be answered
• C. the client who is in the most pain
• D. the client who may have a risk for an airway obstruction

Correct answer: D

Rationale: The nurse should prioritize assessing a client with a potential airway obstruction first based on the ABCs (airway, breathing, circulation) principle. Maintaining a clear airway is crucial for oxygenation and ventilation, making it the highest priority. Choices A and B focus on call bells and waiting times, which are important but not life-threatening in comparison to airway concerns. While pain management is essential, it takes precedence after addressing immediate life-threatening issues like airway compromise.

5. Which of the following lab values is elevated first after a client has a myocardial infarction?

• A. LDH
• B. troponin
• C. CPK
• D. SGOT

Correct answer: B

Rationale: The correct answer is troponin. Troponin levels are the most specific and sensitive markers for myocardial infarction, and they begin to rise within a few hours after the event. CPK, SGOT, and LDH are also enzymes that can indicate myocardial damage, but troponin is the earliest and most specific indicator. CPK typically rises 4-8 hours after an infarction, followed by SGOT (AST) at 8-12 hours, and LDH at 12-24 hours post-infarction.

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