Nursing Elites

1. An adult client with a broken femur is transferred to the medical-surgical unit to await surgical internal fixation after the application of an external traction device to stabilize the leg. An hour after an opioid analgesic was administered, the client reports muscle spasms and pain at the fracture site. While waiting for the client to be transported to surgery, which action should the nurse implement?

• A. Observe for signs of deep vein thrombosis.
• B. Administer a PRN dose of a muscle relaxant.
• C. Check the client’s most recent electrolyte values.
• D. Reduce the weight on the traction device.

Correct answer: B

Rationale: The correct answer is B: Administer a PRN dose of a muscle relaxant. Muscle spasms and pain might be relieved by muscle relaxants, which are appropriate before surgery. Choice A is incorrect because the client is experiencing muscle spasms, not signs of deep vein thrombosis. Choice C is not the most immediate action needed in this situation. Choice D is incorrect because reducing the weight on the traction device would not directly address the muscle spasms and pain reported by the client.

2. The client had gastric bypass surgery yesterday. Which intervention is most important for the nurse to implement during the first 24 postoperative hours?

• A. Insert an indwelling urinary catheter
• B. Monitor for the appearance of an incisional hernia
• C. Instruct the client to eat small frequent meals
• D. Measure hourly urinary output

Correct answer: D

Rationale: Monitoring hourly urinary output is crucial during the first 24 postoperative hours to assess kidney function, fluid balance, and early detection of complications like dehydration or inadequate kidney perfusion. Inserting an indwelling urinary catheter is not routinely necessary after gastric bypass surgery unless there are specific indications. Monitoring for an incisional hernia is important but not the highest priority in the immediate postoperative period. Instructing the client to eat small frequent meals is essential for long-term dietary management after gastric bypass surgery, but not the most critical intervention during the initial 24 hours.

3. What should be the school nurse's first action after being notified that Child A has bitten Child B on the arm, resulting in broken skin but no bleeding?

• A. Apply antibiotic cream to Child B’s arm immediately
• B. Determine if Child A has a history of Hepatitis C or HIV
• C. Determine the date of Child B’s latest tetanus booster
• D. Wash Child B’s arm thoroughly with soap and water

Correct answer: D

Rationale: The correct first action for the school nurse to take in this situation is to wash Child B’s arm thoroughly with soap and water. Washing the wound immediately is crucial to reduce the risk of infection from the bite. Applying antibiotic cream may come after cleaning the wound. Determining Child A's medical history or checking Child B's tetanus status is important but not the immediate priority when dealing with a bite wound.

4. On admission to the Emergency Department, a female client who was diagnosed with bipolar disorder 3 years ago reports that this morning she took a handful of medications and left a suicide note for her family. Which information is most important for the nurse to obtain?

• A. Which family member has the client's suicide note?
• B. When the client last took medications for bipolar disorder?
• C. What medications the client used for the suicide attempt?
• D. Whether the client has ever attempted suicide in the past?

Correct answer: C

Rationale: Identifying the specific medications taken during a suicide attempt is crucial for determining the appropriate treatment and assessing the potential toxicity or interactions. This information helps healthcare providers initiate the necessary interventions promptly. Option A is not as critical as knowing the medications used. Option B focuses on the timing of the last medication intake rather than the specific drugs taken for the overdose. Option D, while relevant, does not provide immediate actionable information compared to identifying the substances involved in the suicide attempt.

5. What instruction should the nurse provide a pregnant client experiencing heartburn?

• A. Limit fluid intake between meals to prevent stomach over-distension
• B. Take an antacid at bedtime and when symptoms worsen
• C. Maintain an upright position for two hours after eating
• D. Eat small meals throughout the day to avoid a full stomach

Correct answer: D

Rationale: The correct answer is D: 'Eat small meals throughout the day to avoid a full stomach.' Heartburn is common in pregnancy due to increased intra-abdominal pressure and hormonal changes. Consuming small, frequent meals prevents the stomach from becoming overly full, reducing the likelihood of acid reflux and heartburn. Choice A is incorrect because limiting fluid intake between meals may not significantly impact heartburn. Choice B is not ideal as antacids should be taken as directed by a healthcare provider, not just at bedtime or when symptoms worsen. Choice C is less effective advice, as maintaining an upright position after eating may not directly address the root cause of heartburn.

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