Nursing Elites

1. A client with a head injury reports severe nausea. What is the nurse's priority action?

• A. Administer anti-nausea medication as prescribed.
• B. Prepare the client for a CT scan.
• C. Elevate the head of the bed and provide an emesis basin.
• D. Notify the healthcare provider immediately.

Correct answer: D

Rationale: Severe nausea in a client with a head injury may be a sign of increased intracranial pressure. The nurse should notify the healthcare provider immediately to ensure timely intervention, as increased pressure can lead to further complications such as brain herniation. Administering anti-nausea medication or preparing for a CT scan may delay necessary treatment for the underlying cause of the nausea, which could be related to the head injury. Elevating the head of the bed and providing an emesis basin may help manage symptoms but should not be the priority over addressing the potential increase in intracranial pressure.

2. A client has viral pneumonia affecting 2/3 of the right lung. What would be the best position to teach the client to lie in every other hour during the first 12 hours after admission?

• A. Side-lying on the left with the head elevated 10 degrees
• B. Side-lying on the left with the head elevated 35 degrees
• C. Side-lying on the right with the head elevated 10 degrees
• D. Side-lying on the right with the head elevated 35 degrees

Correct answer: A

Rationale: The correct answer is side-lying on the left with the head elevated 10 degrees. This position maximizes ventilation and promotes better perfusion to the unaffected lung. Placing the client in this position helps to optimize oxygenation and reduce pressure on the affected lung. Choices B, C, and D are incorrect because lying on the left side with the head elevated is essential to facilitate better lung expansion and gas exchange in the unaffected lung, while lying on the right side could further compromise the affected lung by increasing pressure on it.

3. A client has suspected compartment syndrome of the right lower leg. What is the nurse’s priority intervention?

• A. Elevate the right leg to reduce swelling.
• B. Loosen any restrictive dressings on the leg.
• C. Prepare the client for emergency surgery.
• D. Administer pain medication as prescribed.

Correct answer: B

Rationale: In a suspected case of compartment syndrome, the nurse's priority intervention is to loosen any restrictive dressings on the leg. This action helps to relieve pressure within the affected compartment, improve circulation, and prevent permanent damage. Elevating the leg may further increase pressure, preparing for emergency surgery is premature without proper assessment and diagnosis, and administering pain medication should come after addressing the primary issue of relieving pressure.

4. The nurse is teaching a group of clients about managing diabetes. Which of the following should be emphasized as a goal for all diabetics?

• A. Frequent exercise and weight control
• B. Prevent eye damage
• C. Keep insulin refrigerated at all times
• D. Prevent the development of complications

Correct answer: A

Rationale: The correct answer is A: Frequent exercise and weight control. These should be emphasized as a goal for all diabetics because they help prevent complications and manage blood sugar levels. Regular physical activity and maintaining a healthy weight are crucial in managing diabetes as they can improve insulin sensitivity, regulate blood sugar levels, and reduce the risk of cardiovascular complications. Choice B, preventing eye damage, is important but is more specific to diabetic retinopathy and not a general goal for all diabetics. Choice C, keeping insulin refrigerated, is essential for insulin storage but not a primary goal for all diabetics. Choice D, preventing the development of complications, is too broad and does not provide a specific actionable goal for all diabetics.

5. The nurse is conducting intake interviews of children at a city clinic. Which child is most susceptible to contracting lead poisoning?

• A. An 8-year-old living in a housing project.
• B. A 2-year-old playing on aging playground equipment.
• C. An adolescent working in a paint factory.
• D. A 10-year-old with Type 1 diabetes.

Correct answer: B

Rationale: The correct answer is B. Young children, like the 2-year-old playing on aging playground equipment, are more susceptible to lead poisoning from environmental sources due to their behaviors like hand-to-mouth contact and exploratory behaviors. Choices A, C, and D are less likely to be at high risk for lead poisoning compared to young children due to differences in exposure levels and behaviors related to potential sources of lead contamination.

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