Nursing Elites

1. A nurse is caring for an infant who has coarctation of the aorta. Which of the following should the nurse identify as an expected finding?

• A. Weak femoral pulses.
• B. Frequent nosebleeds.
• C. Upper extremity hypotension.
• D. Increased intracranial pressure.

Correct answer: A

Rationale: Corrected Rationale: Weak femoral pulses are an expected finding in an infant with coarctation of the aorta. The narrowing of the aorta leads to decreased blood flow to the lower extremities, resulting in weak or absent femoral pulses. Frequent nosebleeds (Choice B) are not typically associated with coarctation of the aorta. Upper extremity hypotension (Choice C) is not a common finding in coarctation of the aorta; instead, blood pressure is usually elevated in the upper extremities. Increased intracranial pressure (Choice D) is not directly related to coarctation of the aorta.

2. What is the appropriate intervention when a patient experiences a fall?

• A. Assess for injuries
• B. Call for help
• C. Document the fall
• D. Notify the healthcare provider

Correct answer: A

Rationale: The appropriate intervention when a patient experiences a fall is to assess for injuries. This immediate action helps in identifying any harm or complications resulting from the fall, allowing for timely intervention. Calling for help may be necessary after assessing the injuries, but the priority is to evaluate the patient's condition. Documenting the fall is important for record-keeping purposes but should come after ensuring the patient's safety. Notifying the healthcare provider can be done once the assessment has been completed and any necessary initial interventions have been initiated.

3. A client with iron deficiency anemia has a new prescription for ferrous sulfate. Which of the following instructions should the nurse include?

• A. Take with a glass of milk to prevent stomach upset.
• B. Take with orange juice to enhance absorption.
• C. Take on an empty stomach to increase absorption.
• D. Take with food to reduce gastrointestinal upset.

Correct answer: C

Rationale: The correct instruction is to take ferrous sulfate on an empty stomach to increase absorption. This is because taking it with food or dairy products like milk can reduce its absorption. Orange juice is not recommended as it may interfere with the absorption of iron. Taking ferrous sulfate on an empty stomach may cause gastrointestinal upset, but this can be minimized by gradually increasing the dose.

4. A client has a chest tube connected to a water-seal drainage system. Which of the following actions should be taken?

• A. Clamp the chest tube during ambulation
• B. Keep the collection chamber below the level of the chest
• C. Add sterile water to the water-seal chamber
• D. Empty the collection chamber every 12 hours

Correct answer: C

Rationale: The correct action for the nurse to take when caring for a client with a chest tube connected to a water-seal drainage system is to add sterile water to the water-seal chamber. This is necessary to maintain the correct water level for proper chest tube function. Clamping the chest tube during ambulation (Choice A) is incorrect as it can lead to complications by obstructing drainage. Keeping the collection chamber below the level of the chest (Choice B) is incorrect because it should be kept below the chest to facilitate drainage. Emptying the collection chamber every 12 hours (Choice D) is incorrect as it should be emptied whenever it reaches the fill line or as per facility policy, not on a fixed time schedule.

5. A client receiving a blood transfusion develops a fever. What action should the nurse take?

• A. Stop the transfusion immediately.
• B. Administer an antihistamine as prescribed.
• C. Administer a diuretic as prescribed.
• D. Increase the transfusion rate.

Correct answer: A

Rationale: When a client receiving a blood transfusion develops a fever, the priority action for the nurse is to stop the transfusion immediately. A fever during a blood transfusion may indicate a transfusion reaction, and stopping the transfusion is crucial to prevent further complications. Administering an antihistamine (choice B) or a diuretic (choice C) without assessing and addressing the potential transfusion reaction can be harmful. Increasing the transfusion rate (choice D) is contraindicated as it can exacerbate any adverse reactions the client is experiencing.

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