Nursing Elites

1. In a long term rehabilitation care unit a client with spinal cord injury complains of a pounding headache. The client is sitting in a wheelchair watching television in the assigned room. Further assessment by the nurse reveals excessive sweating, a splotchy rash, pilomotor erection, facial flushing, congested nasal passages and a heart rate of 50. The nurse should do which action next?

• A. Take the client's respirations, blood pressure (BP), temperature and then pupillary responses
• B. Place the client into the bed and administer the ordered PRN analgesic
• C. Check the client for bladder distention and the client's urinary catheter for kinks
• D. Turn the television off and then assist client to use relaxation techniques

Correct answer: C

Rationale: These symptoms suggest autonomic dysreflexia, often triggered by bladder distention.

2. You are teaching a client about the patient-controlled analgesia (PCA) planned for post-operative care. Which statement indicates further teaching may be needed by the client?

• A. ''I will be receiving continuous doses of medication.''
• B. ''I should call the nurse before I take additional doses.''
• C. ''I will call for assistance if my pain is not relieved.''
• D. ''The machine will prevent an overdose.''

Correct answer: B

Rationale: PCA allows patients to self-administer pain medication within prescribed limits, without the need to call the nurse before taking an additional dose. Choice B suggests a misunderstanding of how PCA works, as the patient should be educated that they can self-administer doses within the safety parameters set by the healthcare provider. Choices A, C, and D demonstrate proper understanding of PCA, hence are not indicative of needing further teaching.

3. The healthcare professional enters the room as a 3-year-old is having a generalized seizure. Which intervention should the healthcare professional do first?

• A. Clear the area of any hazards
• B. Place the child on the side
• C. Restrain the child
• D. Give the prescribed anticonvulsant

Correct answer: B

Rationale: Placing the child on the side is the priority intervention during a generalized seizure as it helps maintain an open airway and prevents aspiration. Clearing the area of any hazards is important but should come after ensuring the child's safety. Restraining the child is not recommended during a seizure as it can lead to injury. Giving the prescribed anticonvulsant is important but should not be the first action during an ongoing seizure.

4. Which individual has the highest risk of developing community-acquired pneumonia?

• A. A 40-year-old first-grade teacher who works with underprivileged children.
• B. A 75-year-old retired secretary with exercise-induced wheezing.
• C. A 60-year-old homeless person who is an alcoholic and smokes.
• D. A 35-year-old aerobics instructor who skips meals and eats only vegetables.

Correct answer: C

Rationale: The correct answer is the 60-year-old homeless person who is an alcoholic and smokes. This individual has the highest risk of developing community-acquired pneumonia due to factors such as homelessness, alcoholism, and smoking, which weaken the immune system and make them more susceptible to respiratory infections. Choice A is incorrect as working with underprivileged children, while potentially exposing the individual to various illnesses, does not directly increase the risk of pneumonia. Choice B is less likely as exercise-induced wheezing may suggest asthma but does not directly correlate with pneumonia risk. Choice D, an aerobics instructor who eats only vegetables and skips meals, does not have the same level of risk factors for pneumonia as the homeless person in choice C.

5. A nurse is preparing to administer a tuberculosis (TB) test to a client. Which of the following is the correct method for administering this test?

• A. Intradermal injection on the forearm
• B. Subcutaneous injection on the upper arm
• C. Intramuscular injection on the deltoid
• D. Oral administration

Correct answer: A

Rationale: The correct method for administering a tuberculosis (TB) test is through an intradermal injection on the forearm. This technique allows for the proper administration of the test under the skin to assess the body's response to the TB antigen. Choices B, C, and D are incorrect because the TB test specifically requires an intradermal injection, not subcutaneous, intramuscular, or oral administration.

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