Nursing Elites

1. A child presents to the school nurse with left knee pain after suffering a fall on the playground. Which action should the nurse do first?

• A. Instruct the child to extend the affected knee
• B. Perform range of motion exercises on both knees
• C. Compare the appearance of the left knee to the right knee
• D. Have the child soak the affected knee in warm water

Correct answer: C

Rationale: Comparing the appearance of the left knee to the right knee is the most appropriate initial action as it provides a baseline for assessing any visible differences such as swelling, bruising, or deformities. This comparison helps the nurse identify any acute changes in the affected knee's appearance after the fall. Instructing the child to extend the affected knee (Choice A) may worsen the pain or cause further injury. Performing range of motion exercises on both knees (Choice B) could exacerbate the pain and should be avoided until a proper assessment is done. Having the child soak the affected knee in warm water (Choice D) is not the priority at this stage as assessing for any physical changes is more crucial.

2. In hanging a parenteral IV fluid that is to be infused by gravity, rather than with an infusion pump, the nurse notes that the IV tubing is available in different drop factors. Which tubing is a microdrop set?

• A. 15 drops per milliliter
• B. 60 drops per milliliter
• C. 20 drops per milliliter
• D. 10 drops per milliliter

Correct answer: B

Rationale: A microdrop set delivers 60 drops per milliliter of IV fluid. This allows for a more precise control of the infusion rate. The correct choice is B because it provides the desired microdrop rate. Choices A, C, and D are incorrect. A delivers 15 drops per milliliter, which is a macrodrop set. C delivers 20 drops per milliliter, also a macrodrop set. D delivers 10 drops per milliliter, another macrodrop set. Therefore, the correct choice for a microdrop set is B.

3. Which type of cells secrete insulin?

• A. alpha cells
• B. beta cells
• C. CD4 cells
• D. helper cells

Correct answer: B

Rationale: Beta cells are responsible for secreting insulin. Insulin is produced by beta cells in the pancreas and plays a crucial role in regulating blood sugar levels. Alpha cells secrete glucagon, not insulin (Choice A). CD4 cells are a type of immune cell that helps coordinate the immune response (Choice C). Helper cells are a type of immune cell that aids in activating other immune cells (Choice D). Therefore, the correct answer is beta cells.

4. Which microorganism is most commonly associated with gastritis?

• A. Syphilis
• B. Cytomegalovirus
• C. H. pylori
• D. Mycobacterium

Correct answer: C

Rationale: H. pylori is the most common microorganism associated with gastritis, present in over 80% of cases. While syphilis, cytomegalovirus, and mycobacterium can also cause gastritis, they are much less prevalent compared to H. pylori. Therefore, the correct answer is H. pylori.

5. A client begins a regimen of chemotherapy. Her platelet count falls to 98,000. Which action is least likely to increase the risk of hemorrhage?

• A. Test all excreta for occult blood.
• B. Use a soft toothbrush or foam cleaner for oral hygiene.
• C. Implement reverse isolation.
• D. Avoid IM injections.

Correct answer: C

Rationale: The correct answer is to implement reverse isolation. Reverse isolation is a protective measure used to protect patients from infections, not to affect the risk of hemorrhage. Testing all excreta for occult blood (Choice A) is important to monitor for signs of internal bleeding. Using a soft toothbrush or foam cleaner for oral hygiene (Choice B) is recommended to prevent gum bleeding. Avoiding IM injections (Choice D) is crucial to reduce the risk of bleeding in a client with a low platelet count. Therefore, among the given options, implementing reverse isolation is the least likely to increase the risk of hemorrhage.

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