Nursing Elites

1. When teaching a school-age child and the parent how to administer insulin, which of the following instructions should the nurse include?

• A. Store the insulin in the refrigerator after each use.
• B. Rotate injection sites each time you give the injection.
• C. You should give the insulin at room temperature.
• D. Administer the insulin within 30 minutes of each meal.

Correct answer: C

Rationale: It is essential to give insulin at room temperature to prevent discomfort during administration. Cold insulin can cause stinging and pain, which can be avoided by allowing the insulin to reach room temperature before administration. Storing insulin in the refrigerator is correct for long-term storage, but it should be brought to room temperature before use. Rotating injection sites is important to prevent lipohypertrophy, a condition characterized by fatty lumps that can develop if injections are consistently given in the same area. Administering insulin within 30 minutes of a meal is generally recommended to match the insulin peak action with the peak glucose levels after eating, but giving insulin at room temperature is more crucial to ensure comfort and proper absorption.

2. In the morning, a healthcare professional receives change-of-shift report on four pediatric clients, each of whom has some form of fluid-volume excess. Which of the children should the healthcare professional see first?

• A. The child with tachypnea and pulmonary congestion
• B. The child with hepatomegaly and normal respiratory rate
• C. The child with dependent and sacral edema and regular pulse
• D. The child with periorbital edema and normal respiratory rate

Correct answer: A

Rationale: The child with tachypnea and pulmonary congestion should be seen first. Tachypnea indicates an increased respiratory rate, a sign of possible respiratory distress. Pulmonary congestion suggests fluid accumulation in the lungs, posing a serious risk to respiratory function. Immediate attention is crucial in this case. Choice B is incorrect as hepatomegaly alone does not indicate an acute issue requiring immediate attention. Choices C and D, while showing signs of fluid-volume excess, do not present the same level of respiratory compromise as tachypnea and pulmonary congestion, making them lower priority.

3. A school nurse is assessing a school-age child’s blood pressure while he is seated in a chair. The child starts to experience a tonic-clonic seizure. Which of the following actions should the nurse take first?

• A. Clear the immediate area around the child of hazardous objects
• B. loosen the child’s restrictive clothing
• C. assist the child to a side-lying position on the floor
• D. apply an oxygen mask to the child

Correct answer: C

Rationale: The greatest risk to this child is aspiration, occlusion of the airway, and bodily injury from falling out of the chair. The nurse should ease the child down to the floor in a side-lying position immediately.

4. Following a child's return from exploratory surgery due to a gunshot wound to the abdomen, which nursing intervention should be excluded from the plan of care?

• A. Immediate initiation of oral feedings
• B. Assessment of the surgical site
• C. Administration of opioid narcotics for pain management
• D. Visitation at the bedside

Correct answer: A

Rationale: Immediate initiation of oral feedings should be excluded from the plan of care post-abdominal surgery due to the risk of bowel complications like paralytic ileus or anastomotic leak. Starting oral feedings immediately can increase these risks and hinder healing. It is crucial to wait until bowel function returns and the patient shows signs of tolerance before introducing oral feedings. Assessment of the surgical site is necessary to monitor for any signs of infection or complications. Administration of opioid narcotics for pain management is essential for ensuring the patient's comfort post-surgery. Visitation at the bedside provides emotional support and can aid in the patient's recovery. Therefore, the correct answer is to exclude immediate initiation of oral feedings.

5. A patient is taking a first-generation H1 blocker for the treatment of allergic rhinitis. It is most important for the nurse to assess for which adverse effect?

• A. Skin flushing
• B. Wheezing
• C. Insomnia
• D. Dry mouth

Correct answer: D

Rationale: Adverse Effect of Histamine – First Generation H1 blockers include dry mouth.

Similar Questions