Nursing Elites

1. The client diagnosed with a right fractured femur has skeletal traction applied to the right femur. Which interventions should the nurse implement?

• A. Perform passive range of motion to the right leg
• B. Remove skeletal weights every shift to assess right leg
• C. Turn frequently from prone to supine positions
• D. Maintain skeletal pin sites and assess for signs of infection

Correct answer: D

Rationale: Maintaining skeletal pin sites and assessing for infection are critical in skeletal traction care.

2. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 liters per minute via nasal cannula. The client reports difficulty breathing. What action should the nurse take first?

• A. Increase the oxygen flow rate
• B. Instruct the client to breathe deeply and cough
• C. Check the client's oxygen saturation level
• D. Place the client in a high-Fowler's position

Correct answer: C

Rationale: The correct action for the nurse to take first when a client with COPD reports difficulty breathing while receiving oxygen is to check the client's oxygen saturation level. This helps in determining the adequacy of oxygenation and identifying the cause of the breathing difficulty. Increasing the oxygen flow rate (Choice A) may not be appropriate without knowing the current oxygen saturation level. Instructing the client to breathe deeply and cough (Choice B) may not address the immediate need for oxygen assessment. Placing the client in a high-Fowler's position (Choice D) can help with breathing but should come after ensuring proper oxygenation.

3. A 2-year-old boy with short bowel syndrome has progressed to receiving enteral feedings only. Today his stools are occurring more frequently and have a more liquid consistency. His temperature is 102.2°F and he has vomited twice in the past four hours. Which assessment finding indicates that the child is becoming dehydrated?

• A. Occult blood in the stool
• B. Abdominal distention
• C. Elevated urine specific gravity
• D. Hyperactive bowel sounds

Correct answer: C

Rationale: Elevated urine specific gravity is a sign of dehydration in children. In the scenario provided, the child is experiencing increased stool frequency, liquid consistency, fever, and vomiting, indicating fluid loss and potential dehydration. Occult blood in the stool may suggest gastrointestinal bleeding but is not a direct indicator of dehydration. Abdominal distention can be seen in various conditions and is not specific to dehydration. Hyperactive bowel sounds are more commonly associated with increased bowel motility, not necessarily dehydration.

4. The nurse enters the room of a client with a nasogastric tube who is receiving continuous feeding. The nurse observes that the client is coughing and that the infusion pump is alarming. What action should the nurse take first?

• A. Auscultate the client's breath sounds
• B. Turn the client to the side
• C. Stop the feeding infusion
• D. Notify the healthcare provider

Correct answer: C

Rationale: The correct action for the nurse to take first in this situation is to stop the feeding infusion. Coughing in a client with a nasogastric tube can indicate aspiration, which can be a serious complication. By stopping the feeding infusion immediately, the nurse can prevent further aspiration and related complications. Auscultating breath sounds or turning the client to the side may be necessary actions but addressing the feeding infusion is the priority. Notifying the healthcare provider can be done after the immediate issue of potential aspiration is managed.

5. A male client is admitted to the mental health unit because he experiences panic attacks when driving on the freeway. To attempt to desensitize this fear, what action should the nurse encourage the client to implement?

• A. Watch training videos of people driving in various environments
• B. Begin visualizing himself driving each route to the freeway
• C. Take antianxiety medication two hours before driving on freeways
• D. Get in the car with a support person and drive on a freeway during rush hour

Correct answer: B

Rationale: Visualization techniques, such as visualizing himself driving each route to the freeway, are commonly used in desensitization therapy to help clients gradually overcome their fears. Watching videos of others driving or taking medication do not actively involve the client in facing their fear, which is essential in desensitization therapy. Getting in the car with a support person during rush hour may exacerbate the client's anxiety rather than help in desensitization.

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