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. Lying flat with legs elevated
• C. Lying on the side with the head slightly raised
• D. Sitting up and tilting the head back

Correct answer: A

Rationale: The child with a nosebleed (epistaxis) should be placed in a sitting position, leaning forward, to prevent blood from flowing down the throat. This position helps to control the bleeding and prevents the child from swallowing blood, which can cause nausea or vomiting. Choice B is incorrect because elevating the legs is not recommended for nosebleeds. Choice C is incorrect because lying on the side with the head slightly raised is not the optimal position for managing a nosebleed. Choice D is incorrect because tilting the head back can lead to blood flowing down the throat and potentially cause aspiration.

2. The nurse is caring for a client with a history of myocardial infarction who is experiencing chest pain. Which intervention should the nurse implement first?

• A. Administer oxygen therapy as prescribed.
• B. Obtain an electrocardiogram (ECG).
• C. Administer nitroglycerin sublingually as prescribed.
• D. Administer aspirin as prescribed.

Correct answer: A

Rationale: Administering oxygen therapy is the priority intervention in managing chest pain in a client with a history of myocardial infarction. Oxygen helps improve oxygenation to the heart muscle, which is crucial in reducing further damage. Obtaining an electrocardiogram (ECG) is important to assess for changes indicative of myocardial infarction, but providing oxygen takes precedence as it directly addresses the physiological need for oxygen. Administering nitroglycerin and aspirin are important interventions but are typically implemented after oxygen therapy to address vasodilation and antiplatelet effects, respectively.

3. A client with a history of hypertension is prescribed a beta-blocker. Which client statement indicates that further teaching is needed?

• A. ‘I will take my medication in the morning before breakfast.’
• B. ‘I should avoid eating foods high in potassium.’
• C. ‘I should change positions slowly to avoid dizziness.’
• D. ‘I should avoid abrupt discontinuation of the medication.’

Correct answer: B

Rationale: The correct answer is B: ‘I should avoid eating foods high in potassium.’ This statement indicates a misunderstanding as beta-blockers do not typically affect potassium levels. The other choices (A, C, and D) are all appropriate statements for a client prescribed a beta-blocker. Choice A shows understanding of the timing of medication administration, choice C addresses orthostatic hypotension concerns, and choice D highlights the importance of not abruptly stopping the medication to prevent adverse effects.

4. A client with cirrhosis is admitted with jaundice and ascites. Which intervention should the nurse implement first?

• A. Administer a diuretic as prescribed.
• B. Administer lactulose as prescribed.
• C. Monitor the client's weight daily.
• D. Assess the client's neurological status.

Correct answer: B

Rationale: Administering lactulose is the first priority in managing a client with cirrhosis to reduce ammonia levels and prevent worsening hepatic encephalopathy. Lactulose helps in decreasing the absorption of ammonia in the intestines and promotes its excretion through the stool. This intervention is crucial in preventing the development or progression of hepatic encephalopathy. Administering a diuretic (Choice A) may be necessary to manage ascites, but it is not the priority over lactulose in this scenario. Monitoring the client's weight (Choice C) is important to assess fluid retention but is not the first intervention required. Assessing the client's neurological status (Choice D) is essential in cirrhosis, but administering lactulose takes precedence to prevent hepatic encephalopathy.

5. The nurse is caring for a client with a history of atrial fibrillation who is prescribed warfarin (Coumadin). Which laboratory value should the nurse monitor closely?

• A. Prothrombin time (PT)
• B. Hemoglobin level
• C. International Normalized Ratio (INR)
• D. Serum sodium level

Correct answer: C

Rationale: The INR should be closely monitored in a client prescribed warfarin (Coumadin) to assess the effectiveness and safety of anticoagulation therapy. Monitoring the INR helps determine if the client's blood is clotting appropriately. While prothrombin time (PT) is related to warfarin therapy, the INR is a more precise measure. Hemoglobin level and serum sodium level are not directly related to monitoring warfarin therapy.

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