Nursing Elites

1. A patient is found unconscious in their room with rhythmic jerking of all four extremities and heavy foaming at the mouth. The patient was on seizure precautions with bedrails up and padded. What is the priority action for the nurse to take?

• A. Administer Lorazepam (Ativan)
• B. Turn the patient to his/her side
• C. Call the physician
• D. Suction the patient

Correct answer: B

Rationale: The nurse's priority action should be to turn the patient to his/her side. This position helps maintain an open airway and prevents aspiration of secretions or vomitus. Administering Lorazepam (Ativan) without ensuring a clear airway could lead to further complications. Calling the physician is important, but immediate interventions to protect the airway take precedence. Suctioning the patient may be necessary but should not be the initial action; positioning for airway protection is the priority.

2. After hydrostatic reduction for intussusception, what client response should the nurse expect to observe?

• A. Abdominal distension
• B. Currant jelly-like stools
• C. Severe, colicky-type pain with vomiting
• D. Passage of barium or water-soluble contrast with stools

Correct answer: D

Rationale: After hydrostatic reduction for intussusception, the nurse should observe the passage of barium or water-soluble contrast with stools. This indicates a successful reduction of the telescoped bowel segment. Abdominal distension and currant jelly-like stools are clinical manifestations of intussusception, not expected outcomes following hydrostatic reduction. Severe, colicky-type pain with vomiting suggests an unresolved gastrointestinal issue, not a successful reduction of intussusception.

3. The nurse is reviewing the record of a child diagnosed with nephrotic syndrome. The nurse should expect to note which finding documented in the child's record?

• A. Polyuria
• B. Weight gain
• C. Hypotension
• D. Grossly bloody urine

Correct answer: B

Rationale: In nephrotic syndrome, a key finding documented in the child's record is weight gain due to massive edema. While urine may appear dark, foamy, and frothy, grossly bloody urine is not expected as only microscopic hematuria is present. Additionally, urine output is decreased, and hypertension is likely to be present. Therefore, the correct answer is weight gain as it aligns with the characteristic presentation of nephrotic syndrome.

4. A diabetic patient's arterial blood gas (ABG) results are pH 7.28; PaCO2 34 mm Hg; PaO2 85 mm Hg; HCO3 18 mEq/L. The nurse would expect which finding?

• A. Intercostal retractions
• B. Kussmaul respirations
• C. Low oxygen saturation (SpO2)
• D. Decreased venous O2 pressure

Correct answer: B

Rationale: Kussmaul respirations (deep and rapid) are a compensatory mechanism for metabolic acidosis. The low pH and low bicarbonate levels indicate metabolic acidosis. Intercostal retractions, low oxygen saturation, and decreased venous O2 pressure are not associated with acidosis. Intercostal retractions typically occur in respiratory distress, while low oxygen saturation and decreased venous O2 pressure are more related to respiratory or circulatory issues, not metabolic acidosis.

5. A client using an intraaural hearing aid experiences whistling after placement. What is the nurse's next action?

• A. Try to reposition the hearing aid
• B. Change the batteries
• C. Remove the device and have it cleaned
• D. Notify the physician that the hearing aid is not working

Correct answer: A

Rationale: An intraaural hearing aid, also known as an in-the-ear hearing aid, is placed in the ear canal. Whistling after placement indicates improper positioning of the device. The correct action for the nurse is to try repositioning the hearing aid to eliminate the whistling. Changing the batteries is not necessary for addressing whistling. Removing the device to clean it is not the immediate action needed for whistling. Notifying the physician is premature without attempting to reposition the hearing aid first.

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