Nursing Elites

1. A client is found on the floor of their room experiencing a seizure. Which of the following actions is the priority for the nurse?

• A. Place the client on their side with their head forward
• B. Call for help
• C. Protect the client's head
• D. Restrain the client

Correct answer: A

Rationale: During a seizure, the priority action for the nurse is to place the client on their side with their head forward. This position helps maintain an open airway and prevents aspiration, which is crucial in managing the client's safety during a seizure. Calling for help is important but ensuring the client's immediate safety by positioning them correctly takes precedence. Protecting the client's head can be done concurrently while positioning the client. Restraint is not appropriate during a seizure as it can lead to injuries and complications.

2. A nurse is caring for a client who has a deep vein thrombosis (DVT). Which of the following interventions should the nurse include in the plan of care?

• A. Encourage the client to ambulate frequently.
• B. Apply warm, moist compresses to the affected leg.
• C. Massage the affected leg.
• D. Place the client in a supine position.

Correct answer: B

Rationale: The correct intervention for a client with deep vein thrombosis (DVT) is to apply warm, moist compresses to the affected leg. This helps alleviate pain and improve circulation in the affected area, aiding in the treatment of DVT. Encouraging the client to ambulate frequently (Choice A) is contraindicated as it can dislodge the clot and lead to complications. Massaging the affected leg (Choice C) is also contraindicated as it can dislodge the clot and potentially cause an embolism. Placing the client in a supine position (Choice D) is not specifically indicated for DVT treatment; elevation of the affected leg is preferred over placing the client completely supine.

3. A nurse is assessing a client who is receiving chemotherapy and has stomatitis. Which of the following findings should the nurse expect?

• A. Dry, cracked lips
• B. Bleeding gums
• C. Foul-smelling breath
• D. Red, open sores in the mouth

Correct answer: D

Rationale: The correct answer is D: Red, open sores in the mouth. Stomatitis, a common side effect of chemotherapy, presents with red, open sores in the mouth, which can be painful and increase the risk of infection. Choices A, B, and C are incorrect because stomatitis typically does not manifest as dry, cracked lips, bleeding gums, or foul-smelling breath.

4. A nurse is caring for a newborn who has respiratory distress. Which of the following actions should the nurse take first?

• A. Administer oxygen via nasal cannula
• B. Place the newborn in a prone position
• C. Suction the newborn's airway
• D. Notify the healthcare provider

Correct answer: C

Rationale: In cases of respiratory distress, the nurse should first suction the newborn's airway to clear any obstructions. This is a priority intervention as it helps ensure the airway is patent and allows for effective breathing. Administering oxygen, placing the newborn in a prone position, and notifying the healthcare provider are all important actions but should come after ensuring the airway is clear. Administering oxygen may not be effective if the airway is obstructed. Placing the newborn in a prone position can worsen respiratory distress in infants. While notifying the healthcare provider is important, immediate intervention to clear the airway takes precedence in this situation.

5. A nurse working in a mobile health clinic is assessing a migrant farm worker. What finding should the nurse identify as a priority?

• A. Report of fatigue and fever
• B. Report of muscle twitching and skin rash
• C. Report of blurred vision
• D. Report of nasal congestion

Correct answer: B

Rationale: Muscle twitching and a skin rash may indicate exposure to pesticides, which requires immediate intervention due to potential toxicity. Fatigue and fever (Choice A) are non-specific symptoms that may indicate various conditions but do not directly indicate pesticide exposure. Blurred vision (Choice C) and nasal congestion (Choice D) are also non-specific symptoms and are less likely to be related to pesticide exposure compared to muscle twitching and a skin rash.

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