Nursing Elites

1. When applying an ice bag to a client's ankle following a sports injury, which of the following actions should the nurse take?

• A. Fill the bag two-thirds full with ice.
• B. Apply the ice bag directly to the skin with a barrier.
• C. Keep the ice bag on for more than 30 minutes at a time.
• D. Use a frozen gel pack instead of ice.

Correct answer: A

Rationale: Filling the ice bag two-thirds full is the correct action as it ensures the effectiveness of the ice application while allowing some space for the ice to move and conform to the injury. Choice B is incorrect because the ice bag should be applied with a barrier like a cloth to prevent direct contact with the skin, which can lead to ice burns. Choice C is wrong as ice should typically be applied for 20 minutes at a time to avoid tissue damage. Choice D is also incorrect as ice is preferred over frozen gel packs for immediate sports injury management.

2. A client is being taught how to administer ear drops. Which of the following statements should the nurse identify as an indication that the client understands?

• A. I will straighten my ear canal by pulling my ear down and back.
• B. I will gently apply pressure with my finger to the front part of my ear after putting in the drops.
• C. I will insert the nozzle of the ear drop bottle snugly into my ear before squeezing the drops in.
• D. After the drops are in, I will place a cotton ball all the way into my ear canal.

Correct answer: B

Rationale: The correct answer is B. Gently applying pressure to the front part of the ear after administering drops helps with absorption. Pulling the ear down and back is a correct technique for adults. Snugly inserting the nozzle of the ear drop bottle or placing a cotton ball all the way into the ear canal is unnecessary and can potentially cause harm or discomfort. Therefore, choices A, C, and D are incorrect.

3. A healthcare professional is planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea and who might have a right ear infection. Which of the following routes should the healthcare professional use to obtain the temperature?

• A. Temporal
• B. Oral
• C. Rectal
• D. Axillary

Correct answer: C

Rationale: In a 2-year-old child with diarrhea and a possible ear infection, rectal temperature measurement is the most accurate reflection of core body temperature. This method provides the most reliable reading, especially in young children, as it closely reflects the core body temperature. Oral temperature may not be accurate due to the child's recent diarrhea, which can affect oral readings. Axillary temperature may not be as accurate as rectal temperature in this case. Temporal temperature measurement, although non-invasive, may not provide the most accurate core body temperature reading, especially in a child with a potential ear infection.

4. Before administering the prescribed morphine sulfate to a client post-op following laparotomy who reports pain and dry mouth, what should the nurse do first?

• A. Measure the client's vital signs.
• B. Assess the client's pain level.
• C. Verify the morphine order with another nurse.
• D. Check the client's last dose of morphine.

Correct answer: A

Rationale: Before administering morphine sulfate, it is crucial to measure the client's vital signs to ensure that the client is stable and safe to receive the medication. This step helps identify any contraindications or abnormalities that could affect the administration of morphine. Assessing the client's pain level (choice B) is important, but ensuring the client's physiological stability takes precedence. Verifying the morphine order with another nurse (choice C) and checking the client's last dose of morphine (choice D) are important steps but are not the priority before administering the medication.

5. A client expresses that, based on religious values and mandates, a blood transfusion is not an acceptable treatment option. Which of the following responses should the nurse make?

• A. “I believe in this case you should make an exception and accept the blood transfusion.”
• B. “I know your family would approve of your decision to have a blood transfusion.”
• C. “Why does your religion mandate that you cannot receive any blood transfusions?”
• D. “Let’s discuss the necessity for a blood transfusion with your religious and spiritual leaders and come to a reasonable solution.”

Correct answer: D

Rationale: The correct response is to involve the client's religious and spiritual leaders in the discussion to find a solution that respects both the client's values and medical needs. Option A is incorrect as it dismisses the client's beliefs. Option B assumes the family's opinion over the client's. Option C is inappropriate as it questions the client's religious beliefs rather than addressing the concern respectfully.

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