Nursing Elites

1. Which type of illness is characterized by severe symptoms of relatively short duration?

• A. Chronic Illness
• B. Acute Illness
• C. Pain
• D. Syndrome

Correct answer: B

Rationale: The correct answer is B: Acute Illness. Acute illnesses are characterized by the sudden onset of severe symptoms that typically last for a short duration. These conditions usually resolve within a defined period, unlike chronic illnesses that persist over a longer time frame. Choices C and D, Pain and Syndrome, are not specific types of illnesses but rather symptoms or clinical manifestations that can occur in various health conditions.

2. All of the following interventions are correct when using the Z-track method of drug injection except:

• A. Prepare the injection site with alcohol
• B. Use a needle that is at least 1” long
• C. Aspirate for blood before injection
• D. Rub the site vigorously after the injection to promote absorption

Correct answer: D

Rationale: When using the Z-track method of drug injection, it is important to prepare the injection site with alcohol to ensure cleanliness, use a needle that is at least 1” long to reach the muscle tissue, and aspirate for blood before injection to verify correct needle placement. However, rubbing the site vigorously after the injection is not recommended as it can cause medication to leak into subcutaneous tissue, compromising the medication's intended absorption and efficacy.

3. Which pulse's absence may not be a significant finding when a patient is admitted to the hospital?

• A. Apical
• B. Radial
• C. Pedal
• D. Femoral

Correct answer: C

Rationale: The absence of the pedal pulse may not be significant if the patient has poor peripheral circulation or if the healthcare provider is focused on other pulse points. The pedal pulse is often weaker and may not always be palpable due to various factors, making its absence less concerning in certain situations. However, the absence of other pulses like radial or femoral pulses may indicate more critical conditions and require immediate attention.

4. When planning care for a client with severe acute respiratory distress syndrome (SARS), which of the following actions should not be included in the care plan?

• A. Administer antibiotics
• B. Provide supplemental oxygen
• C. Administer antiviral medications
• D. Administer bronchodilators

Correct answer: A

Rationale: Severe acute respiratory distress syndrome (SARS) is caused by a virus, not bacteria, and antibiotics are ineffective against viral infections. Therefore, administering antibiotics would not be appropriate in the care plan for a client with SARS. The priority interventions for SARS include providing supplemental oxygen to improve oxygenation, administering antiviral medications to target the viral infection, and using bronchodilators to help with bronchospasm or airway constriction. Antibiotics are not indicated unless there is a secondary bacterial infection present.

5. In the emergency department, a nurse is assessing a client involved in a motor vehicle crash. Findings include absent breath sounds in the left lower lobe with dyspnea, blood pressure 118/68 mm Hg, heart rate 124/min, respirations 38/min, temperature 38.6 C (101.4 F), and SaO2 92% on room air. What action should the nurse take first?

• A. Obtain a chest X-ray.
• B. Prepare for chest tube insertion.
• C. Administer oxygen via high-flow mask.
• D. Initiate IV access.

Correct answer: C

Rationale: In this scenario, the client is presenting with signs of respiratory distress, including absent breath sounds, dyspnea, and a low SaO2 level. The priority action should be to improve oxygenation by administering oxygen via a high-flow mask. This intervention aims to increase the oxygen supply to the client's lungs, helping to address the hypoxemia. Once oxygenation is optimized, further interventions, such as obtaining a chest X-ray, preparing for chest tube insertion, or initiating IV access, can be considered based on the client's condition and healthcare provider's orders.

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