Nursing Elites

1. A client who is immobile needs interventions to prevent contractures. Which of the following interventions is appropriate?

• A. Aligning a trochanter wedge between the client's legs.
• B. Placing a towel roll under the client's neck.
• C. Applying an orthotic to the client's foot.
• D. Positioning a pillow under the client's knees.

Correct answer: C

Rationale: Applying an orthotic to the client's foot is the appropriate intervention to prevent contractures in an immobile client. An orthotic helps maintain proper alignment and prevents the development of contractures by keeping the foot in the correct position. Choices A, B, and D are incorrect because a trochanter wedge, towel roll under the neck, and pillow under the knees are not specific interventions for preventing contractures in an immobile client.

2. A client has undergone a bronchoscopy, and a nurse is providing care post-procedure. What should the nurse do first?

• A. Monitor the client's oxygen levels
• B. Encourage the client to eat
• C. Check for a gag reflex
• D. Administer IV fluids

Correct answer: C

Rationale: After a bronchoscopy, the nurse's priority is to check for a gag reflex. This action helps assess the client's ability to protect their airway after sedation. Maintaining airway patency is crucial post-procedure. Monitoring oxygen levels is important but ensuring airway protection takes precedence. Encouraging the client to eat and administering IV fluids are essential aspects of care but are not the immediate priority in this situation.

3. Which of the following is an expected side effect of furosemide?

• A. Bradycardia
• B. Hypokalemia
• C. Increased blood pressure
• D. Increased urine output

Correct answer: B

Rationale: The correct answer is B, Hypokalemia. Furosemide is a loop diuretic that works by increasing the excretion of water and electrolytes, including potassium, leading to hypokalemia. Choice A, Bradycardia, is incorrect because furosemide does not typically cause a decrease in heart rate. Choice C, Increased blood pressure, is incorrect as furosemide is actually used to lower blood pressure by reducing fluid volume. Choice D, Increased urine output, is a common effect of furosemide due to its diuretic action but is not an adverse side effect.

4. A nurse in a provider's office is collecting data from a preschooler. Which of the following findings should the nurse report to the provider?

• A. Heart rate 80/min
• B. Heart rate 90/min
• C. Respiratory rate 28/min
• D. Heart rate 146/min

Correct answer: D

Rationale: A heart rate of 146/min is abnormal for a preschooler and indicates tachycardia, which should be reported to the provider. Choices A, B, and C fall within normal ranges for a preschooler's heart rate (80-120/min) and respiratory rate (22-34/min), so they do not require immediate reporting. Option D is the correct answer as it deviates significantly from the normal range and may indicate an underlying health issue that needs attention.

5. What are the early signs of sepsis in a patient?

• A. Increased heart rate and fever
• B. Low blood pressure and confusion
• C. Elevated blood sugar and sweating
• D. Increased urine output and abdominal pain

Correct answer: A

Rationale: The correct answer is A: Increased heart rate and fever. These are early signs of sepsis and indicate a systemic infection. It is crucial to identify these signs promptly to initiate appropriate treatment. Choice B is incorrect because low blood pressure and confusion are more indicative of severe sepsis or septic shock rather than early signs. Choice C is incorrect as elevated blood sugar and sweating are not typical early signs of sepsis. Choice D is also incorrect as increased urine output and abdominal pain are not early signs of sepsis.

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