Nursing Elites

1. A client with a history of peptic ulcer disease arrives in the emergency department complaining of weakness and states that he vomited 'a lot of dark coffee-looking stomach contents.' The client is cool and moist to the touch. BP 90/50, HR 110, RR 20, T 98. Of the following physician orders, which will the nurse perform first?

• A. Initiate oxygen at 2 liters/nasal cannula.
• B. Start an IV of NS at 150 ml/hr
• C. Insert NG tube to low suction
• D. Attach the client to the ECG monitor

Correct answer: A

Rationale: The correct answer is to initiate oxygen at 2 liters/nasal cannula. The client is presenting signs of shock with hypotension, tachycardia, and cool, moist skin, which indicate poor tissue perfusion. Oxygen should be administered first to improve tissue oxygenation. While all interventions are important, oxygenation takes priority in the ABCs of emergency care. Starting an IV of NS, inserting an NG tube, and attaching the client to the ECG monitor are necessary interventions but should follow the priority of oxygen administration in this scenario.

2. A patient has been admitted to the hospital with an L4-5 HNP diagnosis. After 24 hours, the patient is able to ambulate with assistance and has reduced muscle spasms. Which of the following medications was the most beneficial in changing the patient's mobility status?

• A. Mivacron
• B. Atropine
• C. Bethanechol
• D. Flexeril

Correct answer: D

Rationale: The correct answer is Flexeril. Flexeril is a muscle relaxant commonly used to treat acute muscle pain and spasms. In this scenario, the patient experiencing reduced muscle spasms and improved mobility after taking Flexeril indicates its effectiveness. Choice A, Mivacron, is a neuromuscular blocking agent that is not typically used for muscle spasms or pain relief. Choice B, Atropine, is a medication used to treat certain types of nerve agent and pesticide poisonings, not muscle spasms. Choice C, Bethanechol, is a medication that stimulates bladder contractions and is not indicated for muscle spasms or mobility improvement.

3. A person who had a left CVA and right lower extremity hemiparesis is being instructed by a nurse to use a quad cane. Which of the following is the most appropriate gait sequence?

• A. Place the cane in the patient's left upper extremity, encourage cane, then right lower extremity, then left upper extremity gait sequence.
• B. Place the cane in the patient's left upper extremity, encourage cane, then left lower extremity, then right upper extremity gait sequence.
• C. Place the cane in the patient's right upper extremity, encourage cane, then right lower extremity, then left upper extremity gait sequence.
• D. Place the cane in the patient's right upper extremity, encourage cane, then left lower extremity, then right upper extremity gait sequence.

Correct answer: A

Rationale: The correct gait sequence for a person with left CVA and right lower extremity hemiparesis using a quad cane is to place the cane in the patient's strong upper extremity, which is the left upper extremity in this case. The correct sequence should be right lower extremity followed by left upper extremity, as this pattern mimics a normal gait pattern. Therefore, Choice A is the correct answer. Choices B, C, and D are incorrect because they do not follow the proper gait sequence for this specific patient's condition. The cane should be placed in the strong upper extremity, and the affected lower extremity should move first to provide stability and support, which is essential in this situation.

4. When giving an intramuscular injection to an infant, which of the following sites is preferred?

• A. Ventrogluteal region
• B. Deltoid
• C. Vastus lateralis
• D. Dorsogluteal region

Correct answer: C

Rationale: The correct answer is the Vastus lateralis when giving an intramuscular injection to an infant. The Vastus lateralis muscle, located in the thigh, is the preferred site for infants as it has a larger muscle mass and is well-developed, making it suitable for injections. The Ventrogluteal region and Dorsogluteal region are not recommended for infants due to their smaller muscle mass and potential risk of damaging nearby structures. The Deltoid muscle is typically used for older children and adults, not infants.

5. The nurse is caring for a client with full-thickness burns to the left arm and trunk. What is the priority for this client?

• A. Pain management
• B. Airway assessment
• C. Fluid volume status monitoring
• D. Risk for infection prevention

Correct answer: C

Rationale: Correct! With full-thickness burns, there is a significant risk of fluid loss through the burn wound and fluid shift, leading to hypovolemia and shock. Monitoring and maintaining the client's fluid volume status is crucial to prevent complications like hypovolemic shock. Pain management (Option A) is essential but not the priority in this situation. While airway assessment (Option B) is crucial, it is typically assessed first in clients with respiratory distress. Preventing infection (Option D) is important but managing fluid volume status takes precedence in the initial care of a client with full-thickness burns.

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