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 chronic kidney disease (CKD) who is receiving erythropoietin therapy. Which laboratory value should be closely monitored?

• A. Serum potassium level
• B. Hemoglobin level
• C. White blood cell count
• D. Serum calcium level

Correct answer: A

Rationale: The correct answer is A: Serum potassium level. When a client with chronic kidney disease is receiving erythropoietin therapy, monitoring serum potassium levels is crucial due to the risk of developing hyperkalemia. Erythropoietin can stimulate red blood cell production, leading to an increase in potassium levels. Monitoring potassium helps prevent complications associated with hyperkalemia, such as cardiac arrhythmias. Choices B, C, and D are incorrect because while hemoglobin levels are relevant in assessing the effectiveness of erythropoietin therapy, monitoring potassium levels is more critical in this scenario.

3. A 65-year-old male client with a history of smoking and high cholesterol is admitted with shortness of breath and chest pain. Which diagnostic test should the nurse anticipate preparing the client for first?

• A. Electrocardiogram (ECG)
• B. Chest X-ray
• C. Arterial blood gases (ABGs)
• D. Pulmonary function tests (PFTs)

Correct answer: A

Rationale: The correct answer is an Electrocardiogram (ECG). An ECG should be performed first to assess for cardiac ischemia, especially given the client's symptoms and history. Chest X-ray (Choice B) may be ordered to evaluate the lungs but would not be the initial test for this client presenting with chest pain and shortness of breath. Arterial blood gases (ABGs) (Choice C) are used to assess oxygenation and acid-base balance but are not the primary diagnostic test for a client with suspected cardiac issues. Pulmonary function tests (PFTs) (Choice D) are used to assess lung function and would not be the first test indicated in this scenario.

4. A client with chronic heart failure is receiving furosemide (Lasix). Which laboratory value requires immediate intervention?

• A. Serum potassium of 3.0 mEq/L
• B. Serum sodium of 135 mEq/L
• C. Serum creatinine of 1.5 mg/dl
• D. Blood glucose of 200 mg/dl

Correct answer: A

Rationale: A serum potassium level of 3.0 mEq/L requires immediate intervention in a client receiving furosemide. Furosemide can cause potassium loss, leading to hypokalemia, which can be dangerous, especially in patients with heart failure. Hypokalemia can predispose the client to cardiac dysrhythmias, weakness, and other complications. Therefore, prompt intervention is necessary to prevent these adverse effects. Choice B (Serum sodium of 135 mEq/L) is within the normal range and does not require immediate intervention. Choice C (Serum creatinine of 1.5 mg/dl) may indicate kidney dysfunction but does not pose an immediate threat to the client's safety. Choice D (Blood glucose of 200 mg/dl) may suggest hyperglycemia, which is important but not as urgent as addressing hypokalemia in a client with heart failure receiving furosemide.

5. During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which client alarm should the nurse investigate first?

• A. Respiratory apnea of 30 seconds
• B. Oxygen saturation rate of 88%
• C. Eight premature ventricular beats every minute
• D. Disconnected monitor signal for the last 6 minutes.

Correct answer: A

Rationale: The correct answer is A: Respiratory apnea of 30 seconds. Respiratory apnea indicates a cessation of breathing, which is a life-threatening emergency requiring immediate intervention. Priority should be given to assessing and managing airway, breathing, and circulation. Option B, oxygen saturation rate of 88%, can indicate hypoxemia, but addressing the lack of breathing takes precedence. Option C, eight premature ventricular beats every minute, and option D, a disconnected monitor signal, are important but do not pose an immediate threat to the client's life compared to respiratory apnea.

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