Nursing Elites

1. An adolescent's mother calls the clinic because the teen is having recurrent vomiting and has been combative in the last 2 days. The mother states that the teen takes vitamins, calcium, and magnesium supplements along with aspirin. Which nursing intervention has the highest priority?

• A. Advise the mother to withhold all medications by mouth.
• B. Instruct the mother to take the teen to the emergency room.
• C. Recommend that the teen withhold food and fluids for 2 hours.
• D. Suggest that the adolescent breathe slowly and deeply.

Correct answer: B

Rationale: In this scenario, the highest priority nursing intervention is to instruct the mother to take the teen to the emergency room. The symptoms of recurrent vomiting, combative behavior, and the medications (vitamins, calcium, magnesium supplements, and aspirin) taken by the teen suggest a possible overdose or serious adverse reaction. Therefore, immediate medical evaluation is crucial to assess and manage any potential toxicity or adverse effects. Advising to withhold all medications by mouth (Choice A) may delay necessary treatment. Recommending withholding food and fluids for 2 hours (Choice C) may not address the underlying cause of the symptoms. Suggesting slow and deep breathing (Choice D) is not appropriate in this urgent situation requiring immediate medical attention.

2. The nurse is caring for a client who is postoperative following a thyroidectomy. Which finding requires immediate intervention?

• A. Hoarse voice
• B. Slight difficulty swallowing
• C. Positive Chvostek's sign
• D. Pain at the incision site

Correct answer: C

Rationale: A positive Chvostek's sign indicates hypocalcemia, a common complication following thyroidectomy due to inadvertent parathyroid gland injury. Immediate intervention is needed to prevent severe hypocalcemia symptoms like tetany, seizures, and laryngospasm. Hoarse voice and slight difficulty swallowing are expected post-thyroidectomy and do not require immediate intervention. Pain at the incision site is common postoperatively and can be managed with appropriate pain relief measures.

3. When preparing to insert a nasogastric (NG) tube for a client admitted to the surgical unit with symptoms of a possible intestinal obstruction, which intervention should the nurse implement?

• A. Elevate the head of the bed 60 to 90 degrees
• B. Administer an antiemetic
• C. Prepare the client for surgery
• D. Provide oral care

Correct answer: A

Rationale: Elevating the head of the bed to 60 to 90 degrees is essential when inserting an NG tube. This position helps facilitate the passage of the tube through the esophagus into the stomach and reduces the risk of aspiration. Administering an antiemetic may be necessary to control nausea or vomiting, but it is not the primary intervention when inserting an NG tube. Preparing the client for surgery is not indicated solely for the insertion of an NG tube. Providing oral care is important for maintaining oral hygiene but is not directly related to inserting an NG tube.

4. A client with gestational diabetes, at 39 weeks of gestation, is in the second stage of labor. After delivering the fetal head, the nurse recognizes that shoulder dystocia is occurring. What intervention should the nurse implement first?

• A. Prepare the client for an emergency cesarean birth
• B. Encourage the client to move to a hands-and-knees position
• C. Assist the client to sharply flex her thighs up against the abdomen
• D. Lower the head of the bed and apply suprapubic pressure

Correct answer: C

Rationale: In cases of shoulder dystocia, the priority intervention is to assist the client in sharply flexing her thighs up against the abdomen (McRoberts maneuver). This action helps to widen the pelvic outlet. Encouraging the client to move to a hands-and-knees position may also be beneficial in some cases but is not the first-line intervention. Preparing for an emergency cesarean birth and applying suprapubic pressure are not appropriate initial interventions for shoulder dystocia.

5. A 3-year-old boy with a congenital heart defect is brought to the clinic by his mother. During the assessment, the mother asks the nurse why her child is at the 5th percentile for growth. What response is best for the nurse to provide?

• A. Does your child seem mentally slower than his peers also?
• B. His smaller size is probably due to the heart disease
• C. Haven't you been feeding him according to recommended daily allowances for children?
• D. You should not worry about the growth tables. They are only averages for children

Correct answer: B

Rationale: Heart disease can affect growth, leading to smaller size in children.

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