Nursing Elites

1. What is the first priority for a patient in respiratory distress?

• A. Administer oxygen
• B. Assess airway patency
• C. Monitor oxygen saturation
• D. Call for assistance

Correct answer: A

Rationale: The correct answer is to administer oxygen. In a patient experiencing respiratory distress, the primary concern is ensuring an adequate oxygen supply to the body. By administering oxygen, you can help improve oxygenation, which is crucial for the patient's overall well-being. Assessing airway patency is important but administering oxygen takes precedence as it directly addresses the oxygenation concern. Monitoring oxygen saturation is also essential, but the immediate action should be to provide oxygen. Calling for assistance can be important but is not the first priority when dealing with a patient in respiratory distress.

2. What is the role of the nurse in the care of a patient with a pressure ulcer?

• A. Clean the wound and apply a protective dressing
• B. Assess the wound and reposition the patient frequently
• C. Apply pressure to the ulcer and monitor for signs of healing
• D. Provide pain relief and administer antibiotics as needed

Correct answer: B

Rationale: The correct answer is B: Assess the wound and reposition the patient frequently. When caring for a patient with a pressure ulcer, it is crucial for the nurse to assess the wound regularly to monitor its progress and prevent complications. Additionally, repositioning the patient frequently helps to relieve pressure on the affected area, prevent further damage, and promote healing. Choice A is incorrect because while cleaning the wound is important, applying a protective dressing is not the primary role of the nurse in managing a pressure ulcer. Choice C is incorrect as applying pressure to the ulcer is harmful, and monitoring for signs of healing should not involve applying pressure. Choice D is incorrect as providing pain relief and administering antibiotics may be necessary but are not the primary interventions for managing a pressure ulcer.

3. A nurse is reviewing the medical record of a client with dementia who frequently becomes agitated. What should the nurse prioritize?

• A. Investigate the client's fluid and electrolyte balance
• B. Investigate the client's recent medication changes
• C. Investigate recent changes in cognitive functioning
• D. Investigate the client's psychosocial environment

Correct answer: B

Rationale: The correct answer is to investigate the client's recent medication changes. In a client with dementia who frequently becomes agitated, medication changes can often be a significant factor contributing to their behavior. Checking recent medication changes can help identify if any specific medication is causing or exacerbating the agitation. Choice A about fluid and electrolyte balance is less likely to be the priority unless there are specific indications in the medical record. Choice C, investigating recent changes in cognitive functioning, may be important but addressing the agitation first is a more immediate concern. Choice D, investigating the client's psychosocial environment, is also important but may not directly address the immediate cause of the agitation as medication changes could.

4. A nurse is collecting data from a client who has multiple fractures following a motor-vehicle crash. For which of the following client statements should the nurse recommend a referral to an occupational therapist?

• A. I am frustrated that I cannot lift my arm to comb my hair.
• B. I am upset that I can't hold a pencil anymore.
• C. I am embarrassed that I cannot open my milk carton.
• D. I am so frustrated that I cannot even open my milk carton for breakfast.

Correct answer: D

Rationale: The correct answer is D because the inability to perform activities of daily living, such as opening a milk carton, suggests difficulties with fine motor skills. Occupational therapists specialize in helping individuals regain independence in such tasks. Choices A, B, and C do not specifically address fine motor skills related to activities of daily living, therefore not warranting an occupational therapy referral. Choice A mentions lifting the arm, which involves gross motor skills rather than fine motor skills. Choice B involves holding a pencil, which is more related to hand dexterity and strength rather than fine motor skills. Choice C, opening a milk carton, could be related to fine motor skills but is not as clear-cut as the inability described in Choice D, where the frustration is explicitly about the inability to perform a daily living task.

5. When caring for a client with a wound infection, what is the most important nursing action?

• A. Change the dressing every 4 hours
• B. Perform a wound culture before administering antibiotics
• C. Cleanse the wound with alcohol-based solutions
• D. Apply a wet-to-dry dressing to the wound

Correct answer: B

Rationale: Performing a wound culture before administering antibiotics is crucial in identifying the specific infecting organism and choosing the most effective antibiotic treatment. Changing the dressing every 4 hours (choice A) may be too frequent and can disrupt the wound healing process. Cleansing the wound with alcohol-based solutions (choice C) can be too harsh and may delay healing. Applying a wet-to-dry dressing (choice D) can cause trauma to the wound bed and is not recommended for infected wounds.

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