Nursing Elites

1. When a client is suspected of having a stroke, what is the nurse's priority action?

• A. Administer tissue plasminogen activator (tPA).
• B. Perform a neurological assessment.
• C. Position the client in a supine position.
• D. Check the client's blood glucose level.

Correct answer: B

Rationale: The correct answer is to perform a neurological assessment. When a stroke is suspected, the priority action is to assess the client neurologically to determine the extent of brain injury and identify any immediate risks, such as impaired airway, speech deficits, or loss of motor function. This assessment helps in early recognition of signs that are essential for timely intervention and guides further treatment, such as administering tissue plasminogen activator (tPA), if appropriate. Positioning the client in a supine position or checking the blood glucose level can be important but not the priority when a stroke is suspected.

2. An antibiotic IM injection for a 2-year-old child is ordered. The total volume of the injection equals 2.0 ml. The correct action is to

• A. Administer the medication in 2 separate injections
• B. Give the medication in the dorsal gluteal site
• C. Call to get a smaller volume ordered
• D. Check with the pharmacy for a liquid form of the medication

Correct answer: A

Rationale: Injections over 1 mL should be split into two separate injections for young children. This helps in preventing discomfort, ensuring proper absorption, and reducing the risk of tissue damage. Giving the medication in one injection of 2.0 ml might be too much for a 2-year-old child. Choices B and D are incorrect because the dorsal gluteal site is not recommended for children due to potential injury, and changing the form of medication might not be necessary if the volume can be adjusted. Choice C is unnecessary as splitting the dose into two injections is the appropriate action.

3. After receiving a report on an inpatient acute care unit, which client should the nurse assess first?

• A. Client with pneumonia who has a fever of 101.5°F
• B. Client who underwent knee surgery and needs dressing change
• C. Client with a bowel obstruction due to a volvulus experiencing abdominal rigidity
• D. Client with diabetes requesting insulin

Correct answer: C

Rationale: The correct answer is C. Abdominal rigidity in a client with a bowel obstruction could indicate peritonitis, a serious complication requiring immediate attention. Volvulus, a twisting of the intestine, can lead to bowel ischemia and necrosis. Clients with pneumonia (choice A) may need assessment and treatment for infection, but it is not as immediately life-threatening as a bowel obstruction. A client who underwent knee surgery (choice B) needing a dressing change can typically wait for assessment compared to a potential surgical emergency. Similarly, a client with diabetes requesting insulin (choice D) may require attention to maintain blood glucose levels, but it is not as urgent as a suspected bowel obstruction with possible peritonitis.

4. A client with a venous leg ulcer is receiving compression therapy. What assessment finding requires immediate intervention?

• A. Decreased pain and increased redness around the ulcer.
• B. Increased serous drainage from the ulcer site.
• C. Cool extremities and weak peripheral pulses.
• D. Pitting edema around the ulcer site.

Correct answer: C

Rationale: The correct answer is C. Cool extremities and weak peripheral pulses indicate compromised circulation, possibly due to inadequate arterial blood supply. This finding requires immediate intervention to prevent further complications such as tissue damage or non-healing ulcers. Option A, decreased pain and increased redness, can be a sign of improving wound condition. Option B, increased serous drainage, may indicate a normal part of the healing process. Option D, pitting edema, is common in venous leg ulcers and may not require immediate intervention unless severe and accompanied by other concerning symptoms.

5. A client with a tracheostomy develops copious, thick secretions. What is the nurse's priority action?

• A. Increase the client's fluid intake.
• B. Perform tracheal suctioning.
• C. Administer a mucolytic agent.
• D. Increase the humidity of the oxygen source.

Correct answer: D

Rationale: The correct answer is to increase the humidity of the oxygen source. This action helps thin thick secretions, making them easier to clear from the tracheostomy tube. Increasing fluid intake (Choice A) can be beneficial in some cases but addressing humidity is more specific to managing thick secretions in a client with a tracheostomy. Tracheal suctioning (Choice B) should be done after attempting to thin the secretions with increased humidity. Administering a mucolytic agent (Choice C) is a possible intervention but typically comes after addressing humidity and before resorting to suctioning to avoid unnecessary invasiveness.

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