Nursing Elites

1. When administering a shot of Vitamin K to a 30-day-old infant, which of the following target areas is the most appropriate?

• A. Gluteus maximus
• B. Gluteus minimus
• C. Vastus lateralis
• D. Vastus medialis

Correct answer: C

Rationale: When administering medications to infants, it is common to use the vastus lateralis muscle in the thigh for injections. The preferred site is the junction of the upper and middle thirds of the vastus lateralis muscle. This area provides a good muscle mass for the injection and minimizes the risk of hitting nerves or blood vessels. The gluteus maximus and gluteus minimus are not typically used for infant injections due to the risk of injury to the sciatic nerve. The vastus medialis is not as commonly used as the vastus lateralis for infant injections.

2. A two-year-old child has sustained an injury to the leg and refuses to walk. The nurse in the emergency department documents swelling of the lower affected leg. Which of the following does the nurse suspect is the cause of the child's symptoms?

• A. Possible fracture of the tibia.
• B. Bruising of the gastrocnemius muscle.
• C. Possible fracture of the radius.
• D. No anatomic injury, the child wants his mother to carry him.

Correct answer: A

Rationale: The child's refusal to walk, along with swelling of the lower leg, indicates a possible fracture, specifically of the tibia. Fractures can cause pain and swelling, leading to difficulty or refusal to bear weight on the affected limb. Choice B, bruising of the gastrocnemius muscle, would not typically result in the child refusing to walk. Choice C, a possible fracture of the radius, is less likely given the location of the swelling and the associated refusal to walk. Choice D, stating no anatomic injury and attributing the child's behavior to wanting to be carried by the mother, is incorrect as the physical findings suggest a potential fracture that needs to be evaluated further.

3. A female patient with atrial fibrillation has the following lab results: Hemoglobin of 11 g/dl, a platelet count of 150,000, an INR of 2.5, and potassium of 2.7 mEq/L. Which result is critical and should be reported to the physician immediately?

• A. Hemoglobin of 11 g/dl
• B. Platelet count of 150,000
• C. INR of 2.5
• D. Potassium of 2.7 mEq/L

Correct answer: D

Rationale: The critical lab result that should be reported to the physician immediately in this case is the potassium level of 2.7 mEq/L. A potassium imbalance, especially in a patient with a history of dysrhythmia like atrial fibrillation, can be life-threatening and lead to cardiac distress. Low potassium levels (hypokalemia) can predispose the patient to dangerous arrhythmias, including worsening atrial fibrillation. Hemoglobin of 11 g/dl, platelet count of 150,000, and an INR of 2.5 are within acceptable ranges and not as immediately concerning as a low potassium level in this clinical context.

4. When taking the blood pressure (BP) on the right arm of a patient with severe acute pancreatitis, the nurse notices carpal spasms of the patient's right hand. Which action should the nurse take next?

• A. Ask the patient about any arm pain.
• B. Retake the patient's blood pressure.
• C. Check the calcium level in the chart.
• D. Notify the healthcare provider immediately.

Correct answer: C

Rationale: In this scenario, the nurse observed carpal spasms in the patient's right hand, indicating a positive Trousseau's sign, which is associated with hypocalcemia. Patients with acute pancreatitis are at risk for hypocalcemia, hence the nurse should promptly check the calcium level in the chart to assess the patient's condition. Notifying the healthcare provider comes after confirming the calcium level. There is no indication to ask about arm pain or to retake the blood pressure, as the primary concern is addressing the potential hypocalcemia.

5. While receiving normal saline infusions to treat a GI bleed, the nurse notes that the patient's lower legs have become edematous and auscultates crackles in the lungs. What should the nurse do first?

• A. Stop the saline infusion immediately
• B. Notify the physician
• C. Elevate the patient's legs
• D. Continue the infusion, as these findings are normal

Correct answer: A

Rationale: The correct answer is to stop the saline infusion immediately. The patient is showing signs of fluid volume overload due to rapid fluid replacement, indicated by lower leg edema and lung crackles. Continuing the infusion could worsen the overload and potentially lead to complications. Notifying the physician is important but should come after stopping the infusion to address the immediate issue. Elevating the patient's legs may help with edema but is not the priority in this situation. Continuing the infusion when the patient is already showing signs of fluid overload is contraindicated and can be harmful.

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