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. During the initial visit to a client with MS who is bed-bound and lifted by a hoist, which intervention is most important for the nurse to implement?

• A. Determine how the client is cared for when the caregiver is not present.
• B. Develop a client needs assessment and review it with the caregiver.
• C. Evaluate the caregiver's ability to care for the client's needs.
• D. Review with the caregiver the interventions provided each day.

Correct answer: A

Rationale: During the initial visit, the most crucial intervention for the nurse is to determine how the client is cared for when the caregiver is not present. This is essential to ensure the client's safety and well-being, especially during times when the caregiver is not available. Option B is not the most important as it focuses on assessment rather than immediate safety concerns. Option C, while important, is secondary to ensuring continuous care. Option D is less critical during the initial visit compared to ensuring care continuity in the caregiver's absence.

3. An adult male who lives alone is brought to the Emergency Department by his daughter. He is unresponsive, with minimal respiratory effort, and his pupils are fixed and dilated. At the daughter's request, the client is intubated and mechanically ventilated. Which nursing intervention has the highest priority?

• A. Offer to notify the client's minister of his condition.
• B. Determine if the client has an executed living will.
• C. Provide the family with information about palliative care.
• D. Explore the possibility of organ donation with the family.

Correct answer: B

Rationale: The highest priority nursing intervention in this scenario is to determine if the client has an executed living will. A living will provides guidance on the client's preferences for medical care in situations where they cannot communicate. This information is crucial in guiding the care team on how to proceed with treatment. Options A, C, and D, though important in certain circumstances, are not the highest priority in this situation where immediate decisions regarding the client's care need to be made.

4. The nurse is reinforcing home care instructions with a client who is being discharged following a transurethral resection of the prostate (TURP). Which intervention is most important for the nurse to include in the client teaching?

• A. Avoid strenuous activity for 6 weeks.
• B. Report fresh blood in the urine.
• C. Take acetaminophen for a fever over 101°F.
• D. Consume 6 to 8 glasses of water daily.

Correct answer: B

Rationale: Reporting fresh blood in the urine is crucial as it may indicate postoperative complications requiring immediate attention. This symptom can be a sign of bleeding, infection, or other issues that need prompt medical evaluation. Avoiding strenuous activity for 6 weeks is important but not as urgent as reporting fresh blood. Taking acetaminophen for a fever over 101°F is relevant but addressing fresh blood in the urine takes precedence. Consuming an adequate amount of water daily is beneficial but not as critical as recognizing and reporting signs of potential complications.

5. After a third hospitalization 6 months ago, a client is admitted to the hospital with ascites and malnutrition. The client is drowsy but responding to verbal stimuli and reports recently spitting up blood. What assessment finding warrants immediate intervention by the nurse?

• A. Bruises on arms and legs
• B. Round and tight abdomen
• C. Pitting edema in lower legs
• D. Capillary refill of 8 seconds

Correct answer: D

Rationale: In this situation, the client's capillary refill of 8 seconds is the assessment finding that warrants immediate intervention by the nurse. A capillary refill greater than 3 to 5 seconds indicates poor perfusion, which could be a sign of inadequate circulation and oxygenation. Checking capillary refill is a quick and useful way to assess peripheral perfusion. Bruises on arms and legs may indicate a bleeding disorder but are not as urgent as addressing poor perfusion. A round and tight abdomen could suggest ascites, which is already known in this case. Pitting edema in lower legs is a common finding in malnutrition and ascites but does not require immediate intervention as poor capillary refill does.

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