Nursing Elites

1. Parents of a 6-month-old child, who has just been diagnosed with iron deficiency anemia, ask why it was not diagnosed earlier. What would be the best response by the nurse?

• A. Are you sure your child has iron deficiency anemia?
• B. This happens when the maternal stores of iron are depleted at about 6 months.
• C. This anemia is caused by blood loss.
• D. The child may not have had it for a long time.

Correct answer: B

Rationale: The best response by the nurse would be choice B: 'This happens when the maternal stores of iron are depleted at about 6 months.' Iron deficiency anemia becomes apparent at about 6 months of age in a full-term infant when the maternal stores of iron are depleted. Choice A is incorrect because it questions the diagnosis provided by the healthcare provider. Choice C is incorrect because iron deficiency anemia in infants is primarily due to insufficient iron intake rather than blood loss. Choice D is incorrect as iron deficiency anemia typically develops gradually due to inadequate iron intake.

2. What is a priority action for the nurse when caring for a client with suspected meningitis?

• A. Isolate the client in a private room
• B. Administer intravenous antibiotics
• C. Obtain a throat culture
• D. Perform a chest x-ray

Correct answer: B

Rationale: Administering intravenous antibiotics is the priority when caring for a client with suspected meningitis. The prompt administration of antibiotics is crucial to treat bacterial meningitis and prevent potential complications. Isolating the client in a private room may be necessary to prevent the spread of infection, but antibiotic administration takes precedence. Obtaining a throat culture and performing a chest x-ray are important diagnostic measures, but they do not address the immediate need for antibiotic therapy in suspected bacterial meningitis.

3. The nurse is triaging clients who have been injured during a tornado. Which client requires immediate action?

• A. A young male with a minor laceration on his forearm.
• B. An elderly woman with a dislocated shoulder who is calm.
• C. A middle-aged female with a broken humerus who is unable to follow commands and is crying.
• D. A teenager with abrasions and a bruised knee.

Correct answer: C

Rationale: The middle-aged female with a broken humerus who is unable to follow commands and is crying requires immediate action. These symptoms indicate a possible head injury or severe emotional distress that need urgent attention. Choice A is not as urgent since a minor laceration can be addressed after more critical cases. Choice B, although having a dislocated shoulder, is stable, as the client is calm. Choice D presents with minor injuries that can wait while more critical cases are addressed.

4. A client with a history of hypertension is admitted with a blood pressure of 220/120 mm Hg. What is the priority nursing action?

• A. Administer antihypertensive medication as prescribed.
• B. Place the client in a supine position.
• C. Obtain a detailed health history.
• D. Monitor urine output.

Correct answer: A

Rationale: Administering antihypertensive medication is the priority nursing action in this situation. The extremely high blood pressure of 220/120 mm Hg puts the client at risk of severe complications such as stroke, heart attack, or kidney damage. Lowering the blood pressure promptly is crucial to prevent these complications. Placing the client in a supine position or obtaining a detailed health history are not immediate actions needed to address the hypertensive crisis. Monitoring urine output, although important, is not the priority when the client's blood pressure is critically high.

5. Which nursing intervention promotes achievement of the goal 'optimal mobility' for a client who had a total hip replacement 8 hours ago?

• A. Encourage the client to use an abductor pillow when ambulating.
• B. Teach the client to perform leg exercises in bed.
• C. Assist the client to sit at the edge of the bed.
• D. Assist the client to turn while an abductor pillow is between the legs.

Correct answer: D

Rationale: Assisting the client to turn while an abductor pillow is between the legs is the correct intervention to promote optimal mobility for a client who had a total hip replacement 8 hours ago. Using an abductor pillow helps maintain hip alignment and prevents dislocation, which are crucial considerations in the early postoperative period. Encouraging the client to use an abductor pillow when turning is more beneficial compared to the other options: teaching leg exercises in bed, encouraging the use of a walker when ambulating, or assisting the client to sit at the edge of the bed, as these interventions may not directly address the specific needs of a client after a total hip replacement.

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