Nursing Elites

1. What is the most appropriate action when a patient is experiencing confusion after surgery?

• A. Administer oxygen
• B. Reposition the patient
• C. Administer IV fluids
• D. Perform a neurological exam

Correct answer: A

Rationale: Administering oxygen is the most appropriate action when a patient is experiencing confusion after surgery because it helps alleviate hypoxia, which may be causing the patient's confusion. Repositioning the patient would not directly address the potential hypoxia issue. Administering IV fluids may be necessary for hydration or other reasons but is not the initial priority in addressing confusion post-surgery. Performing a neurological exam may be important later on to assess the patient's neurological status but should not be the first action taken when confusion is present.

2. What is the priority intervention for a patient with a severe allergic reaction?

• A. Administer epinephrine
• B. Administer corticosteroids
• C. Administer oxygen
• D. Administer antihistamines

Correct answer: A

Rationale: The correct answer is to administer epinephrine. Epinephrine is the first-line treatment for severe allergic reactions because it rapidly reverses the symptoms of anaphylaxis by constricting blood vessels, increasing heart rate, and relaxing airway muscles. Corticosteroids, although helpful to reduce inflammation, are not the priority in the acute management of severe allergic reactions. Oxygen may be needed to support breathing, but it is not the initial priority. Antihistamines are not as effective as epinephrine in treating severe allergic reactions and should not be the first intervention.

3. A nurse is teaching a newly licensed nurse about the stages of wound healing. The nurse should include in the teaching that collagen is added to the wound during which of the following stages?

• A. Hemostasis phase.
• B. Inflammatory phase.
• C. Proliferative phase.
• D. Maturation phase.

Correct answer: C

Rationale: The correct answer is C: Proliferative phase. During the proliferative phase of wound healing, collagen is added to the wound to promote tissue regeneration. In the hemostasis phase (choice A), the primary goal is to stop bleeding by forming a blood clot. The inflammatory phase (choice B) involves cleaning the wound and preparing it for healing. The maturation phase (choice D) is when the wound undergoes remodeling and gains strength, but collagen addition primarily occurs during the proliferative phase.

4. A nurse in an emergency department is assessing a client who reports ingesting thirty diazepam tablets and has a respiratory rate of 10/min. After securing the client's airway and initiating an IV, which of the following actions should the nurse do next?

• A. Monitor the client's IV site for thrombophlebitis
• B. Administer flumazenil to the client
• C. Evaluate the client for further suicidal behavior
• D. Initiate seizure precautions for the client

Correct answer: B

Rationale: Administering flumazenil is the priority to reverse the effects of diazepam overdose. Monitoring the IV site for thrombophlebitis (choice A) is important but not the next immediate action. Evaluating the client for further suicidal behavior (choice C) is important but not the priority at this moment. Initiating seizure precautions (choice D) is not the priority action in this scenario.

5. A nurse in an emergency department is caring for a client who reports cocaine use 1hr ago. Which of the following findings should the nurse expect?

• A. Hypotension
• B. Memory loss
• C. Slurred speech
• D. Elevated temperature

Correct answer: D

Rationale: The correct answer is D: Elevated temperature. Cocaine is a stimulant drug that can lead to an increase in body temperature. Hypotension (choice A) is less likely as cocaine tends to increase blood pressure. Memory loss (choice B) and slurred speech (choice C) are not typically immediate effects of recent cocaine use.

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