Nursing Elites

1. Which of the following injuries, if demonstrated by a client entering the Emergency Department, is the highest priority?

• A. open leg fracture
• B. open head injury
• C. stab wound to the chest
• D. traumatic amputation of a thumb

Correct answer: C

Rationale: A stab wound to the chest might result in lung collapse and mediastinal shift that, if untreated, could lead to death. Treatment of an obstructed airway or a chest wound is a higher priority than hemorrhage. The principle of ABC (airway, breathing, and circulation) prioritizes care decisions. In this scenario, the stab wound to the chest poses the highest risk to the client's life as it can lead to severe complications such as lung collapse and mediastinal shift. Addressing this injury promptly is crucial to prevent further harm or potential fatality. Open leg fracture, open head injury, and traumatic amputation of a thumb, while serious, do not pose an immediate life-threatening risk compared to a stab wound to the chest.

2. How can the nurse promote relief of muscle pain, spasms, and tension?

• A. Encouraging the client to continue their activities as usual.
• B. Immobilizing the client.
• C. Applying heat, cold, pressure, or vibration to the painful area.
• D. Administering pain medication as needed to ease the muscle.

Correct answer: C

Rationale: To promote relief of muscle pain, spasms, and tension, the nurse should consider applying heat, cold, pressure, or vibration to the painful area. These interventions can help alleviate pain associated with muscle tension, pain, or spasms. Choice A is incorrect because encouraging the client to continue their activities as usual may exacerbate the pain. Choice B is incorrect as immobilizing the client may not address the underlying issue and could potentially lead to further complications. Choice D is also incorrect because while pain medication can be used, it is not the first-line treatment for muscle pain, spasms, and tension.

3. Which deficiency in the mother has been primarily associated with neural tube defects in the fetus?

• A. Iron
• B. Folic acid
• C. Vitamin B12
• D. Vitamin E

Correct answer: B

Rationale: Folic acid deficiency in the mother has been primarily associated with neural tube defects in the fetus. Folic acid is crucial for the development of the neural tube in the early stages of pregnancy. Its deficiency can lead to neural tube defects, such as spina bifida or anencephaly. Iron deficiency is not directly related to neural tube defects but can cause other complications in pregnancy. Vitamin B12 is important for neurological function but is not the primary cause of neural tube defects. Vitamin E deficiency is not associated with neural tube defects in the fetus.

4. The nurse is obtaining a health assessment from the preoperative client scheduled for hip replacement surgery. Which statement by the client would be most important for the nurse to report to the physician?

• A. "I had chickenpox when I was 8 years old."?
• B. "I had rheumatic fever when I was 10 years old."?
• C. "I have a strong family history of gastric cancer."?
• D. "I have pain in my hip with any movement."?

Correct answer: B

Rationale: The most important statement for the nurse to report to the physician is that the client had rheumatic fever when they were 10 years old. This information is crucial as individuals who have had rheumatic fever require pre-medication with antibiotics before any surgical or dental procedure to prevent bacterial endocarditis. Reporting this history ensures the client's safety during the hip replacement surgery. The other options, such as having chickenpox in the past, a family history of gastric cancer, or experiencing hip pain, are important for the client's overall health assessment but do not have the same immediate implications for the upcoming surgery as the history of rheumatic fever.

5. After discontinuing a peripherally inserted central line (PICC), what information is most important for the nurse to record?

• A. How the client tolerated the procedure.
• B. The length and intactness of the central line catheter.
• C. The amount of fluid left in the IV solution container.
• D. That a dressing was applied to the insertion site.

Correct answer: B

Rationale: The most important information for the nurse to record after discontinuing a peripherally inserted central line (PICC) is the length and intactness of the central line catheter. This is crucial for assessing any potential complications or safety issues post-removal. Choices A, C, and D are not as critical as ensuring the condition of the central line catheter. While noting the client's tolerance of the procedure is relevant for their care assessment, evaluating the central line's integrity takes precedence in this scenario.

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