Nursing Elites

1. The nurse is obtaining the medical histories of new clients at a community-based primary care clinic. Which individual has the highest risk for experiencing elder abuse?

• A. A 69-year-old widowed female who lives alone and volunteers at a school
• B. A 95-year-old ambulatory male who resides in a nursing home in a small town
• C. A 78-year-old female on a fixed income who lives with her relatives
• D. An 81-year-old male with diabetes who lives with his wife of 52 years

Correct answer: C

Rationale: Elder abuse risk is higher in individuals who live with relatives and are on a fixed income as these factors can contribute to vulnerability. Living with relatives may expose the individual to potential abusive situations within the family dynamics. Additionally, being on a fixed income may limit financial independence and increase dependency on others, potentially leading to financial abuse. The other options, such as living alone and volunteering, residing in a nursing home, or living with a long-term spouse, do not inherently pose the same level of risk factors for elder abuse as living with relatives on a fixed income.

2. An 8-year-old child who weighs 60 pounds receives an order for Polycilin (Ampicillin) suspension 25 mg/kg/day divided into a dose every 8 hours. The medication is labeled '125 mg/5 ml'. How many ml should the nurse administer per dose every 8 hours?

• A. 5
• B. 10
• C. 15
• D. 20

Correct answer: A

Rationale: Calculate the daily dose first: 60 pounds x 25 mg/kg = 1500 mg/day. Divide by 3 doses = 500 mg/dose. Convert to mL: (500 mg / 125 mg) x 5 ml = 20 ml. However, the question asks for the dose per administration every 8 hours, which is 1/3 of the daily dose. So, the correct calculation should be (20 ml / 3) = 6.67 ml, which rounds to 5 ml. Therefore, the correct answer is 5 ml. Choice B (10 ml) is incorrect because it doesn't consider the frequency of dosing. Choice C (15 ml) is incorrect as it overestimates the dose. Choice D (20 ml) is incorrect as it represents the total daily dose, not the dose per administration every 8 hours.

3. What nursing intervention is particularly indicated for the second stage of labor?

• A. Providing pain medication to increase the client’s tolerance of labor
• B. Assessing the fetal heart rate and pattern for signs of fetal distress
• C. Monitoring effects of oxytocin administration to help achieve cervical dilation
• D. Assisting the client to push effectively so that the expulsion of the fetus can be achieved

Correct answer: D

Rationale: During the second stage of labor, assisting the client to push effectively is crucial for the delivery of the fetus. This action helps to facilitate the expulsion of the fetus from the uterus. Providing pain medication (Choice A) is not typically done during the second stage of labor as the focus shifts to pushing and delivery. Assessing the fetal heart rate (Choice B) is important but is more relevant throughout labor, not specifically for the second stage. Monitoring the effects of oxytocin administration (Choice C) is more associated with the first stage of labor to help with uterine contractions and cervical dilation.

4. The nurse is caring for a group of clients on a surgical unit. Which client should the nurse assess first?

• A. A client who is two days post knee surgery and describes pain at a “4” on a 1 to 10 scale
• B. A client who is one day post bowel resection with no bowel sounds
• C. A client who is 8 hours post appendectomy with urinary output of 480 ml
• D. A client who was admitted with severe abdominal pain and suddenly has no pain

Correct answer: D

Rationale: The correct answer is D. A sudden absence of pain in a client with severe abdominal pain may indicate a serious condition such as internal bleeding. This sudden change in pain status requires immediate assessment to rule out any life-threatening complications. Choices A, B, and C do not indicate an acute change in the client's condition that would necessitate immediate attention compared to sudden pain relief in a client with severe abdominal pain.

5. A school nurse is called to the soccer field because a child has a nosebleed (epistaxis). In what position should the nurse place the child?

• A. Sitting up and leaning forward
• B. Reclining with head elevated
• C. Sitting up with head tilted back
• D. Lying flat on the back

Correct answer: A

Rationale: The correct position for a child with a nosebleed (epistaxis) is sitting up and leaning forward. This position helps prevent blood from flowing into the throat and causing choking. Choice B, reclining with the head elevated, and choice D, lying flat on the back, are incorrect as they can cause blood to flow backward into the throat. Choice C, sitting up with the head tilted back, is also incorrect as it can lead to blood flowing down the back of the throat and potentially into the airway.

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