Nursing Elites

1. An 8-year-old child is placed in 90-90 traction for a fractured femur. The nurse notices that the weights are touching the foot of the bed. What action should the nurse take?

• A. No bowel movement for two days
• B. Mother helps reposition the child
• C. Ensure weights are not touching the foot of the bed
• D. Child wiggles toes freely when tickled

Correct answer: C

Rationale: The nurse should ensure that the weights in traction are not touching the foot of the bed. This is crucial to maintain proper alignment and effectiveness of the traction. When the weights touch the bed, it can compromise the traction's function and delay healing. Choices A, B, and D are incorrect as they do not address the issue of ensuring that the weights are not touching the bed, which is essential for the traction to work effectively.

2. A nurse is reviewing the basal body temperature method with a couple. Which of the following statements would indicate that the teaching has been successful?

• A. I don't need to buy a special type of thermometer.
• B. I need to wait 5 minutes after smoking a cigarette before I take my temperature.
• C. I need to take my temperature before I get out of bed in the morning.
• D. I need to take my temperature at least once every day.

Correct answer: C

Rationale: The correct answer is C. Basal body temperature must be taken before getting out of bed in the morning to get an accurate reading, as even slight activity can raise body temperature and affect the results. Choice A is incorrect because a special type of thermometer is not required for basal body temperature measurement. Choice B is incorrect because smoking can affect body temperature, but the timing mentioned is not relevant to basal body temperature measurement. Choice D is incorrect because while it is essential to take the temperature consistently each day, the duration of temperature measurement is not specified, making this choice less specific compared to the correct answer.

3. A client post-splenectomy is at risk for infection. What is the most important preventive measure the nurse should emphasize during discharge teaching?

• A. Take all prescribed antibiotics as directed.
• B. Avoid crowded places and people who are sick.
• C. Wash hands frequently and practice good hygiene.
• D. Keep the surgical site clean and dry.

Correct answer: C

Rationale: The correct answer is C: 'Wash hands frequently and practice good hygiene.' After a splenectomy, the client is at an increased risk of infection due to the role of the spleen in the immune system. Maintaining good hand hygiene, such as frequent handwashing, is crucial to prevent infections. While taking prescribed antibiotics as directed (Choice A) is important if prescribed, it is not the most crucial preventive measure in this scenario. Avoiding crowded places and sick people (Choice B) can help reduce the risk of exposure to pathogens but may not always be feasible. Keeping the surgical site clean and dry (Choice D) is important for wound care but is not the primary preventive measure to protect against infections in a post-splenectomy client.

4. When administering parenteral iron, which action would be inconsistent with proper administration?

• A. Using the Z-track method
• B. Using an air bubble to avoid withdrawing medication into subcutaneous tissue
• C. Not massaging the injection site
• D. Using the deltoid muscle for administration

Correct answer: D

Rationale: The correct answer is D: Using the deltoid muscle for administration. Administering parenteral iron in the deltoid muscle is not recommended due to the risk of irritation and pain. The Z-track method (choice A) is preferred to prevent staining and irritation of the skin when administering irritating medications like iron. Using an air bubble (choice B) to avoid withdrawing medication into subcutaneous tissue is a common practice to ensure accurate administration. Not massaging the injection site (choice C) is also a standard practice to prevent potential irritation or bleeding at the injection site.

5. The nurse enters a male client's room to administer routine morning medications, and the client is on the phone. Which action is best for the nurse to take?

• A. Ask another nurse to return with the medication when the client has hung up the phone
• B. Wait for the client to excuse himself from the telephone conversation, and observe the client taking the medication
• C. Return the medication to the client's drawer on the cart and document that the client refused the dose
• D. Leave the medication with the client and let him take it when he finishes the conversation

Correct answer: B

Rationale: The best action for the nurse to take in this situation is to wait for the client to excuse himself from the telephone conversation and then observe the client taking the medication. This approach ensures that the client takes the medication as prescribed, promoting compliance and safety. Choice A is not ideal as it involves unnecessary delegation and may lead to confusion. Choice C is incorrect because assuming refusal without direct communication can compromise patient care. Choice D is not recommended as leaving the medication with the client unsupervised may result in non-compliance or potential errors.

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