Nursing Elites

1. A client has hyperthermia. Which of the following actions should the nurse take?

• A. Submerge the client's feet in ice water.
• B. Cover the client with a thermal blanket.
• C. Administer oral acetaminophen.
• D. Initiate seizure precautions.

Correct answer: C

Rationale: Administering oral acetaminophen is the appropriate intervention for a client with hyperthermia. Acetaminophen helps to reduce fever by lowering the body's temperature. Submerging the client's feet in ice water can lead to shock and is not recommended. Using a thermal blanket may worsen the condition by trapping heat. Initiating seizure precautions is not directly related to managing hyperthermia.

2. A client is postoperative following a rhinoplasty, and a nurse is contributing to the plan of care. Which of the following interventions should the nurse recommend?

• A. Administer humidified oxygen
• B. Restrict fluids
• C. Instruct the client to avoid the Valsalva maneuver
• D. Apply heat packs to the nose

Correct answer: C

Rationale: Instructing the client to avoid the Valsalva maneuver is crucial after rhinoplasty to reduce strain and the risk of bleeding. Administering humidified oxygen may not be directly related to postoperative care for rhinoplasty. Restricting fluids is not typically necessary unless specifically indicated by the healthcare provider. Applying heat packs to the nose is contraindicated after rhinoplasty as it can increase the risk of bleeding and should be avoided.

3. A nurse is collecting data from a school-age child who has sustained a skull fracture. Which of the following is a manifestation of increased intracranial pressure?

• A. Nausea
• B. Confusion about own name
• C. Rapid pulse
• D. Vomiting

Correct answer: B

Rationale: Confusion, especially about one's own name, is a sign of increased intracranial pressure and should be addressed. Nausea and vomiting are common symptoms of increased intracranial pressure, but confusion about personal information is a more specific and critical indication that requires immediate attention. Rapid pulse may be a possible response to increased intracranial pressure, but it is not as specific as confusion about own name in this scenario.

4. When caring for a client diagnosed with delirium, what condition should the nurse prioritize investigating?

• A. Investigate medication history
• B. Investigate sensory deficits
• C. Investigate cognitive functioning
• D. Investigate for signs of infection

Correct answer: D

Rationale: The correct answer is to investigate for signs of infection when caring for a client diagnosed with delirium. Infections can frequently cause or worsen delirium. While investigating medication history, sensory deficits, and cognitive functioning may be important in the overall care of the client, when prioritizing, the nurse should first rule out or address potential infections due to their significant impact on delirium.

5. A nurse is teaching a client how to administer enoxaparin. Which of the following instructions should the nurse include?

• A. Inject the medication into the muscle of the thigh
• B. Massage the injection site after administration
• C. Pinch the skin before injecting
• D. Administer the medication at the same time each day

Correct answer: C

Rationale: The correct instruction for administering enoxaparin is to pinch the skin before injecting. Pinching the skin helps create a proper fold for subcutaneous injections like enoxaparin, ensuring proper delivery of the medication into the subcutaneous tissue. Choice A is incorrect because enoxaparin should be administered subcutaneously, not into the muscle. Injecting it into the muscle can lead to complications. Choice B is incorrect because massaging the injection site after administration can increase the risk of bleeding or bruising due to the anticoagulant properties of enoxaparin. Choice D is incorrect as it is a general instruction and does not specifically relate to the administration of enoxaparin.

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