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 newly diagnosed with gastroesophageal reflux disease (GERD) is being taught about dietary management by a nurse. Which instruction should the nurse include?

• A. Avoid drinking milk
• B. Eat three large meals a day
• C. Avoid eating spicy foods
• D. Increase fluid intake with meals

Correct answer: C

Rationale: The correct instruction for a client with GERD is to avoid eating spicy foods. Spicy foods can exacerbate GERD symptoms by irritating the esophagus and increasing stomach acid production. Avoiding spicy foods can help reduce discomfort and prevent further irritation. Choices A, B, and D are incorrect. Drinking milk is not advised for GERD as it can trigger acid production. Eating three large meals a day can put pressure on the stomach, worsening symptoms. Increasing fluid intake with meals can lead to bloating and worsen GERD symptoms by causing the stomach to expand, pushing more acid into the esophagus.

3. The nurse-manager of a perinatal unit is notified that one client from the medical-surgical unit needs to be transferred to make room for new admissions. Which client should the nurse recommend for transfer to the antepartal unit?

• A. A 45-year-old with chronic hepatitis B.
• B. A 35-year-old with lupus erythematosus
• C. A 19-year-old diagnosed with rubella
• D. A 25-year-old with herpes lesions of the vulva

Correct answer: B

Rationale: The correct answer is B because a client with lupus erythematosus can be safely transferred to the antepartal unit as this condition does not pose a significant risk to other patients or staff. Choices A, C, and D should not be recommended for transfer to the antepartal unit due to the potential risks they may pose to pregnant women and their unborn babies. Chronic hepatitis B, rubella, and herpes lesions of the vulva can be contagious and harmful in the perinatal setting.

4. Which assessment finding is most indicative of deep vein thrombosis (DVT) in a client's right leg?

• A. Dorsiflexes the right foot and left on command
• B. A 3 by 5 cm ecchymosis area covering the right calf
• C. Right calf is 3 cm larger in circumference than the left
• D. Bilateral lower extremity has 3+ pitting edema

Correct answer: C

Rationale: The correct answer is C because a significant increase in the circumference of the right calf compared to the left calf is a classic sign of deep vein thrombosis (DVT). Option A is incorrect as dorsiflexing the right foot and left on command does not specifically indicate DVT. Option B describes an ecchymosis area which is more indicative of a bruise rather than DVT. Option D suggests bilateral lower extremity edema, which is not specific to DVT and can be seen in various conditions such as heart failure or renal issues.

5. The nurse is preparing to administer an IM injection to a 6-month-old child. Which injection site is best for the nurse to use?

• A. Vastus lateralis
• B. Deltoid
• C. Ventrogluteal
• D. Dorsogluteal

Correct answer: A

Rationale: The vastus lateralis is the preferred site for IM injections in infants due to muscle development. In infants under 1 year old, the vastus lateralis muscle in the thigh is often used for IM injections due to its size and development. The deltoid muscle is typically used for adults, and the ventrogluteal and dorsogluteal sites are more commonly used for older children and adults. Therefore, the best choice for administering an IM injection to a 6-month-old child is the vastus lateralis.

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