Nursing Elites

1. A school nurse is called to the soccer field because a child has a nosebleed (epistaxis). In what position should the nurse place the child?

• A. Sitting up and leaning forward
• B. Reclining with head elevated
• C. Sitting up with head tilted back
• D. Lying flat on the back

Correct answer: A

Rationale: The correct position for a child with a nosebleed (epistaxis) is sitting up and leaning forward. This position helps prevent blood from flowing into the throat and causing choking. Choice B, reclining with the head elevated, and choice D, lying flat on the back, are incorrect as they can cause blood to flow backward into the throat. Choice C, sitting up with the head tilted back, is also incorrect as it can lead to blood flowing down the back of the throat and potentially into the airway.

2. An adult male with a 6 cm thoracic aneurysm is being prepared for surgery. The nurse reports to the healthcare provider that the client’s blood pressure is 220/112 mmHg, so an antihypertensive agent is added to the client’s IV infusion. Which finding warrants immediate intervention by the nurse?

• A. Reports a tearing, sharp pain between his shoulder blades
• B. Blood pressure reading of 200/100 mmHg 15 minutes later
• C. Rose-colored urine draining from the urinary catheter
• D. Sinus tachycardia with frequent premature ventricular beats (PVC)

Correct answer: A

Rationale: A tearing, sharp pain between the shoulder blades may indicate aortic dissection, a serious complication requiring immediate intervention. This symptom is highly concerning in a patient with a thoracic aneurysm. Choice B is not as urgent as the pain symptom described in choice A. Choice C could indicate hematuria but is not as critical as the potential aortic dissection in choice A. Choice D, sinus tachycardia with PVCs, may be related to the patient's condition but is not as indicative of an immediate life-threatening situation as the tearing, sharp pain indicative of aortic dissection.

3. Before administering an intramuscular injection, the nurse's finger is stuck with the needle. Which action should the nurse take?

• A. Go to the emergency room to have blood drawn
• B. Prepare the medication using a new syringe
• C. Apply clean gloves before giving the medication
• D. Review the medical history in the client's chart

Correct answer: B

Rationale: In this scenario, if the nurse's finger is stuck with the needle before administering the injection, the correct action is to prepare the medication using a new syringe. This step is crucial to prevent contamination and ensure the safety of the patient. Going to the emergency room to have blood drawn is unnecessary and does not address the immediate issue of contamination. Applying clean gloves is important for infection control but does not address the potential contamination from the needlestick. Reviewing the medical history in the client's chart is important for overall patient care but is not the priority in this situation where immediate action is required to prevent harm.

4. Why is it important to initiate nursing interventions that promote good nutrition, rest, exercise, and stress reduction for clients diagnosed with an HIV infection?

• A. Prevent the spread of infection to others
• B. Improve the function of the immune system
• C. Increase the ability to carry out activities of daily living
• D. Promote a feeling of general well-being

Correct answer: B

Rationale: The correct answer is B: 'Improve the function of the immune system.' Initiating interventions focusing on good nutrition, rest, exercise, and stress reduction aims to enhance the immune system function in clients with HIV infection. For individuals with HIV, maintaining a strong immune system is crucial in fighting the virus and preventing opportunistic infections. Choices A, C, and D are important aspects of care but are secondary to the primary goal of boosting the immune system to combat the effects of the HIV virus.

5. A client who sustained a pellet gun injury with a resulting comminuted skull fracture is admitted overnight for observation. Which assessment finding obtained two hours after admission necessitates immediate intervention?

• A. The client complains of a throbbing headache rated 10 (on a scale of 1 to 10)
• B. The client repeatedly falls asleep while talking with the nurse
• C. The entry site has a slow trickle of bright red blood
• D. The entry site appears reddened and edematous

Correct answer: B

Rationale: In a client with a pellet gun injury and a comminuted skull fracture, repeatedly falling asleep while talking with the nurse is a concerning sign. It can indicate increased intracranial pressure or a deteriorating condition, requiring immediate intervention. The other options, such as a throbbing headache (choice A), slow trickle of bright red blood at the entry site (choice C), or reddened and edematous entry site (choice D), while important to monitor, do not directly indicate a need for immediate intervention as much as the client falling asleep repeatedly while talking does.

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