Nursing Elites

1. A male client with muscular dystrophy fell in his home and is admitted with a right hip fracture. His right foot is cool, with palpable pedal pulses. Lungs are coarse with diminished bibasilar breath sounds. Vital signs are temperature 101 degrees F, heart rate 128 beats/minute, respirations 28 breaths/minute, and blood pressure 122/82. Which intervention is most important for the nurse to implement first?

• A. Obtain oxygen saturation level.
• B. Encourage incentive spirometry.
• C. Assess lower extremity circulation
• D. Administer PRN oral antipyretic.

Correct answer: D

Rationale: Administering an antipyretic is the most important intervention. The client presents with an elevated temperature, tachycardia, and tachypnea, indicating a fever. Lowering the temperature with an antipyretic is crucial to prevent complications like dehydration, altered mental status, and increased oxygen demand. While assessing lower extremity circulation and oxygen saturation are important, addressing the elevated temperature takes priority in this scenario. Incentive spirometry may be beneficial but is not the priority compared to managing the fever.

2. Which signs/symptoms would be considered classical signs of meningeal irritation?

• A. Positive Kernig sign, diarrhea, and headache
• B. Negative Brudzinski sign, positive Kernig sign, and irritability
• C. Positive Brudzinski sign, positive Kernig sign, and photophobia
• D. Negative Kernig sign, vomiting, and fever

Correct answer: C

Rationale: The correct answer is C: Positive Brudzinski sign, positive Kernig sign, and photophobia are considered classical signs of meningeal irritation. The Kernig sign is positive when the leg is extended at the knee and then raised, resulting in pain and resistance. The Brudzinski sign is positive when flexing the neck causes flexion of the hips and knees due to meningeal irritation. Photophobia, or sensitivity to light, is a common symptom due to meningeal inflammation. Choices A, B, and D are incorrect because they do not include the classic signs associated with meningeal irritation.

3. When conducting a class for parents about sudden infant death syndrome (SIDS), the nurse instructs the class that the infant should be placed in which position to sleep?

• A. Right side-lying
• B. Left side-lying
• C. Prone
• D. Supine

Correct answer: D

Rationale: The correct answer is D, supine. The American Academy of Pediatrics recommends placing infants on their back, or supine, to sleep as it has been shown to reduce the risk of SIDS. Choices A, B, and C are incorrect because placing infants on their right side, left side, or prone (on their stomach) respectively are not recommended sleeping positions due to the increased risk of SIDS associated with those positions.

4. An adolescent female asks the nurse about taking retinoic acid (Accutane). What guidance should be provided by the nurse?

• A. The medication should be used for 10 weeks only.
• B. The medication requires that sexually active females use contraception.
• C. The medication lowers hemoglobin levels very quickly.
• D. The medication has few side effects.

Correct answer: B

Rationale: The correct guidance the nurse should provide is that sexually active females must use contraception while taking Accutane and for 1 month after the 20 weeks it is prescribed. Choice A is incorrect because Accutane is typically taken for a longer duration than 10 weeks. Choice C is incorrect because Accutane does not lower hemoglobin levels quickly. Choice D is incorrect as Accutane is known for having many side effects, including the risk of birth defects.

5. The parents of a child who has had a myringotomy are instructed by the nurse to place the child in which position?

• A. Supine
• B. On the affected side
• C. On the unaffected side
• D. In Trendelenburg's position

Correct answer: B

Rationale: Placing the child on the affected side after a myringotomy facilitates ear drainage. This position helps prevent accumulation of fluids in the ear canal, aiding in the healing process. Placing the child in the supine position (Choice A) or on the unaffected side (Choice C) may not be as effective in promoting drainage. The Trendelenburg's position (Choice D) with the head lower than the body is used for conditions requiring increased venous return, not for post-myringotomy care.

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