Nursing Elites

1. The nurse caring for a hospitalized older client with a left hip fracture as a result of a fall at home notices different assessment findings. Which assessment finding warrants immediate intervention by the nurse?

• A. Pain rated 7/10 on the pain scale.
• B. Mild swelling at the fracture site.
• C. Small amount of bleeding from the surgical site.
• D. Left extremity capillary refill greater than 5 seconds.

Correct answer: D

Rationale: The correct answer is D. A left extremity capillary refill greater than 5 seconds indicates poor blood flow to the extremity, which is a sign of compromised circulation. This finding requires immediate intervention by the nurse to prevent complications such as tissue damage or necrosis. Choices A, B, and C are important assessments but do not indicate an immediate need for intervention like the delayed capillary refill in choice D.

2. When selecting patient problems for the 4-year-old child with nephrosis, what should be a priority for the nurse?

• A. Impaired body image
• B. Skin impairment
• C. Nutritional deficit
• D. Injury

Correct answer: B

Rationale: The correct answer is B: Skin impairment. Nephrosis is characterized by gross edema, making skin care a priority. Skin impairment can result from the edema and needs close monitoring and management. While nutritional deficit and injury are important considerations in patient care, they are not the priority when dealing with a child with nephrosis. Impaired body image is not typically a priority in the immediate care of a young child with nephrosis.

3. Since children with attention deficit hyperactivity disorder (ADHD) take medication for long periods of time, side effects must be considered. How often should children be assessed for side effects of the drug therapy?

• A. Every 2 months
• B. Every 4 months
• C. Every 6 months
• D. Every 8 months

Correct answer: C

Rationale: Children with ADHD who are on long-term medication therapy should be assessed for side effects every 6 months. This timeframe allows healthcare providers to monitor the effects of the medication and make any necessary adjustments. Checking every 2 months (Choice A) may be too frequent and not practical for routine monitoring, while checking every 4 or 8 months (Choices B and D) may lead to missing potential side effects or delays in addressing them.

4. The nurse is caring for a child who has been diagnosed with attention deficit hyperactivity disorder (ADHD). What is the most important intervention for the nurse?

• A. Help the child enroll in a special education class.
• B. Allay any feelings of guilt the parents may have.
• C. Explain to the parents that medications are lifelong.
• D. Teach the parents how to set limits.

Correct answer: B

Rationale: The most important intervention for the nurse in caring for a child with ADHD is to allay any feelings of guilt the parents may have. Parents of children with ADHD often experience guilt or self-blame, thinking they are responsible for their child's condition. By addressing and alleviating these feelings, the nurse can support the parents in a crucial way. Choice A is not the most important intervention because enrolling the child in a special education class might be a consideration but does not address the emotional needs of the parents. Choice C is incorrect because stating that medications are lifelong may cause unnecessary distress to the parents. Choice D is also not the most important intervention as setting limits is important but not as critical as addressing parental guilt and emotions.

5. Laboratory findings indicate that a client’s serum potassium level is 2.5 mEq/L. What action should the nurse take?

• A. Administer potassium supplements orally.
• B. Increase the client's dietary potassium intake.
• C. Inform the healthcare provider of the need for potassium replacement.
• D. Monitor the client's ECG continuously.

Correct answer: C

Rationale: A serum potassium level of 2.5 mEq/L is critically low, indicating severe hypokalemia. In this situation, it is essential for the nurse to inform the healthcare provider promptly about the need for potassium replacement. Administering potassium supplements orally or increasing dietary potassium intake is not appropriate in cases of critically low potassium levels as immediate and precise replacement is necessary. Monitoring the client's ECG continuously is important in severe cases of hypokalemia, but the priority action should be to inform the healthcare provider for further management and treatment.

Similar Questions