Nursing Elites

1. A family came to the emergency department with complaints of food poisoning. Which client should the nurse see first?

• A. 32-year-old with diarrhea for 6 hours
• B. 2-year-old with 1 wet diaper in 24 hours
• C. 40-year-old with abdominal cramping
• D. 10-year-old who is nauseated

Correct answer: B

Rationale: The correct answer is B because a 2-year-old with reduced urine output (1 wet diaper in 24 hours) is at high risk for dehydration. Dehydration can occur rapidly in young children and can be life-threatening. The nurse should prioritize assessing and managing the dehydration of the 2-year-old. Choices A, C, and D, although they may also require attention, do not present the same level of immediate risk as a dehydrated 2-year-old.

2. The nurse supervises care of a client in Buck’s traction. The nurse determines that care is appropriate if which of the following is observed? (Select all that apply)

• A. The nurse removes the foam boot three times per day to inspect the skin
• B. The staff turn the client to the unaffected side
• C. The staff turn the client to the unaffected side and the nurse asks the client to dorsiflex the foot on the affected leg
• D. The nurse asks the client to dorsiflex the foot on the affected leg

Correct answer: C

Rationale: Correct care for a client in Buck’s traction includes turning the client to the unaffected side to prevent complications such as pressure ulcers. Additionally, asking the client to dorsiflex the foot on the affected leg helps prevent foot drop. Removing the foam boot three times per day to inspect the skin is unnecessary and could disrupt the traction, so it is not appropriate. Therefore, choices A and D are incorrect.

3. The client is diagnosed with pericarditis. When assessing the client, the nurse is unable to auscultate a friction rub. Which action should the nurse implement?

• A. Notify the healthcare provider
• B. Document that the pericarditis has resolved
• C. Ask the client to lean forward and listen again
• D. Prepare to insert a unilateral chest tube

Correct answer: C

Rationale: The correct action for the nurse to implement when unable to auscultate a pericardial friction rub in a client diagnosed with pericarditis is to ask the client to lean forward and listen again. Leaning forward can help bring the heart closer to the chest wall, making it easier to detect the rub. Option A (Notifying the healthcare provider) is incorrect because further assessment is needed before escalating the situation. Option B (Documenting that the pericarditis has resolved) is incorrect as the absence of a friction rub does not necessarily mean resolution. Option D (Preparing to insert a unilateral chest tube) is incorrect as this intervention is not indicated for the absence of a friction rub.

4. The nurse is caring for a client whose religious background is Seventh Day Adventist (Church of GOD). Which nursing action(s) are most appropriate in terms of providing for the dietary needs of this client? Select all that apply.

• A. Providing snacks between meals
• B. Excluding caffeine and pork from the client's diet
• C. Removing coffee from the breakfast tray
• D. Ensuring that there is no pork on the dinner tray

Correct answer: B

Rationale: The correct answer is B. Seventh Day Adventists typically avoid caffeine and pork due to religious dietary restrictions. Providing snacks between meals (choice A) is not specifically related to the dietary needs of this client. While removing coffee from the breakfast tray (choice C) aligns with the client's dietary restrictions, ensuring no pork on the dinner tray (choice D) is redundant as it is already covered in the correct answer. Therefore, choices C and D are not necessary to include as separate options.

5. Warfarin (Coumadin) is an anticoagulant and interferes with the action of:

• A. Platelets
• B. Vitamin K
• C. Calcium
• D. Vitamin B12

Correct answer: B

Rationale: The correct answer is B: Vitamin K. Warfarin inhibits the action of vitamin K, which is essential for blood clotting. By interfering with the production of certain clotting factors, warfarin helps prevent blood clots. Choices A, C, and D are incorrect because warfarin primarily affects the vitamin K-dependent clotting factors and not platelets, calcium, or vitamin B12.

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