Nursing Elites

1. What should be the school nurse's first action after being notified that Child A has bitten Child B on the arm, resulting in broken skin but no bleeding?

• A. Apply antibiotic cream to Child B’s arm immediately
• B. Determine if Child A has a history of Hepatitis C or HIV
• C. Determine the date of Child B’s latest tetanus booster
• D. Wash Child B’s arm thoroughly with soap and water

Correct answer: D

Rationale: The correct first action for the school nurse to take in this situation is to wash Child B’s arm thoroughly with soap and water. Washing the wound immediately is crucial to reduce the risk of infection from the bite. Applying antibiotic cream may come after cleaning the wound. Determining Child A's medical history or checking Child B's tetanus status is important but not the immediate priority when dealing with a bite wound.

2. In Duchenne muscular dystrophy, if a child has a Gower sign, what behavior should the nurse expect the child to exhibit?

• A. Stands from sitting on the floor by using hands to walk up legs
• B. Exhibits muscular atrophy of upper and lower extremities
• C. Is unable to stand because of contractures of both hips
• D. Walks with an unsteady gait and slaps feet on the floor

Correct answer: A

Rationale: The Gower sign is a characteristic finding in Duchenne muscular dystrophy where a child uses hands to walk up the legs when standing from a sitting position due to proximal muscle weakness. This behavior is indicative of the child trying to compensate for weak hip and thigh muscles. Choices B, C, and D are incorrect because they do not describe the specific behavior associated with the Gower sign. Muscular atrophy, contractures of both hips, and an unsteady gait with foot slapping are not directly related to the Gower sign.

3. A client with a history of myocardial infarction (MI) is receiving a beta-blocker medication. What is the most important outcome for the nurse to monitor?

• A. Heart rate and blood pressure
• B. Blood glucose levels
• C. Respiratory rate
• D. Liver function tests

Correct answer: A

Rationale: The correct answer is A: Heart rate and blood pressure. When a client with a history of myocardial infarction (MI) is on a beta-blocker medication, monitoring heart rate and blood pressure is crucial. Beta-blockers lower heart rate and blood pressure, so monitoring these parameters helps assess the medication's effectiveness and prevent complications like bradycardia or hypotension. Choices B, C, and D are not the most important outcomes to monitor in this scenario. Blood glucose levels are typically monitored in clients with diabetes or when using medications that affect glucose levels. Respiratory rate is important in assessing respiratory function and oxygenation, while liver function tests are more relevant when monitoring the impact of medications on liver health.

4. The nurse is assessing a client with Addison's disease who is weak, dizzy, disoriented, and has dry oral mucous membranes, poor skin turgor, and sunken eyes. Vital signs are blood pressure 94/44, heart rate 123 beats/minute, respiration 22 breaths/minute. Which intervention should the nurse implement first?

• A. Assess extremity strength and resistance
• B. Report a sodium level of 132 mEq/L or mmol/L (SI units)
• C. Measure and record the cardiac QRS complex
• D. Check current finger stick glucose

Correct answer: D

Rationale: The client’s symptoms suggest possible adrenal crisis or hypoglycemia. Checking glucose is a priority to rule out hypoglycemia, which requires immediate intervention. The client is presenting with symptoms indicative of hypoglycemia, which can be life-threatening if not promptly addressed. Assessing extremity strength, reporting sodium levels, or measuring the cardiac QRS complex are not the most urgent actions in this scenario.

5. A client morning assessment includes bounding peripheral pulses, weight gain of 2 pounds, pitting ankle edema, and moist crackles bilaterally. Which intervention is most important for the nurse to include in this client’s plan of care?

• A. Restrict daily fluid intake to 1500 ml
• B. Weight the client every morning
• C. Maintain accurate intake and output
• D. Administer prescribed diuretic

Correct answer: D

Rationale: Administering a prescribed diuretic is the most important intervention in this scenario as the client is presenting signs of fluid overload and heart failure. Diuretics help reduce fluid retention in the body, alleviating symptoms like edema and crackles. Restricting fluid intake may be necessary in some cases, but in this acute situation, addressing the immediate fluid overload with a diuretic takes precedence. Weighing the client daily and maintaining accurate intake and output are important aspects of monitoring, but they do not directly address the urgent need to manage fluid overload.

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