Nursing Elites

1. A young boy is recently diagnosed with a seizure disorder. Which of the following statements by the boy's mother indicates a need for further teaching by the nurse?

• A. "I should make sure he gets plenty of rest."?
• B. "I should get him a medical alert bracelet."?
• C. "I should lay him on his back during a seizure."?
• D. "I should loosen his clothing during a seizure."?

Correct answer: C

Rationale: The correct answer is '"I should lay him on his back during a seizure."?' When a client is having a seizure, it is crucial to turn them onto their side to prevent aspiration of secretions. Placing them on their back can lead to potential airway compromise. Choices A, B, and D are correct statements that indicate a good understanding of caring for a child with a seizure disorder: ensuring rest, getting a medical alert bracelet for identification, and loosening clothing to facilitate breathing during a seizure.

2. A nurse is preparing to administer medications to a client via a nasogastric (NG) tube. Before administering the medication, the nurse must first take which action?

• A. Check the client's apical pulse
• B. Check when the last feeding was given
• C. Check the placement of the tube
• D. Check when the last medications were given

Correct answer: C

Rationale: Before administering medications through an NG tube, the nurse must first check the placement of the tube to prevent aspiration. This is done by aspirating gastric contents and measuring the pH. Checking the client's apical pulse is unrelated to NG tube medication administration. Checking when the last feeding was given is important but not a priority before administering medications. Checking when the last medications were given is also not directly related to ensuring the safe administration of medications through an NG tube. Ensuring the correct placement of the tube is crucial to prevent complications such as pulmonary aspiration.

3. A health care provider writes a medication prescription in a client's record. While transcribing the prescription, the nurse notes that the prescribed dose is three times higher than the recommended dose. The nurse calls the health care provider, who states that this is the dose that the client takes at home and that it is acceptable for this client's condition. What is the appropriate action for the nurse to take?

• A. Verifying the prescribed dose with the client before administering the medication
• B. Contacting the nursing supervisor
• C. Asking the nurse assigned to care for the client to administer the medication
• D. Continuing to transcribe the prescription

Correct answer: B

Rationale: In this scenario, the nurse has identified a significant discrepancy between the prescribed dose and the recommended dose. While the health care provider has justified the higher dose based on the client's home regimen, the nurse's primary responsibility is to ensure patient safety. If a nurse has concerns about a prescription being incorrect or potentially harmful, they should seek further clarification from the health care provider. Since the nurse still believes the dose is inappropriate after discussing with the health care provider, the next appropriate action is to contact the nursing supervisor. Continuing to transcribe the prescription without addressing the concern could jeopardize the client's safety. Asking another nurse to administer the medication without proper resolution of the dosage concern would also pose a risk to the client. While verifying the prescribed dose with the client is important, in this situation, the nurse should first escalate the issue to the nursing supervisor to ensure appropriate actions are taken.

4. How many feet should separate the nurse and the source when extinguishing a small, wastebasket fire with an appropriate extinguisher?

• A. 1 foot
• B. 2 feet
• C. 4 feet
• D. 6 feet

Correct answer: D

Rationale: The nurse should stand about 6 feet from the source of the fire. Getting closer might put the nurse in danger. Choice A, 1 foot, is incorrect because it is too close to the fire and can expose the nurse to unnecessary risk. Choice B, 2 feet, is also too close to the fire and may lead to potential harm. Similarly, choice C, 4 feet, is not the ideal distance as it is still within the range of potential danger. The correct answer is D, 6 feet, which is a safe distance for the nurse to extinguish the fire effectively without risking personal safety.

5. Following an automobile accident that caused a head injury to an adult client, the nurse observes that the client sleeps for long periods of time. The nurse determines that the client has experienced injury to the:

• A. hypothalamus.
• B. thalamus.
• C. cortex.
• D. medulla.

Correct answer: A

Rationale: The hypothalamus is responsible for regulating sleep patterns among other functions. Injury to the hypothalamus can disrupt the sleep-wake cycle, leading to excessive sleepiness or changes in sleep patterns. Choices B, C, and D are incorrect as they do not primarily control sleep regulation. The thalamus is involved in relaying sensory information, the cortex is responsible for higher brain functions, and the medulla controls vital functions such as heartbeat and breathing.

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