Nursing Elites

1. The nurse is preparing a client for surgery who was admitted to the emergency center following a motor vehicle collision. The client has an open fracture of the femur and is bleeding moderately from the bone protrusion site.

• A. Ensure the client is NPO and document the last meal.
• B. Administer pain medication as prescribed.
• C. Apply a sterile dressing to the wound site.
• D. Notify the healthcare provider of the client’s medication history.

Correct answer: D

Rationale: In this scenario, the priority action is to notify the healthcare provider of the client's medication history. This is important because understanding the client’s medication history, especially if they are taking anticoagulants or other medications that could affect bleeding and surgery, is crucial in ensuring safe management of the client's condition. Option A, ensuring the client is NPO and documenting the last meal, is important but not the priority in this situation. Administering pain medication (Option B) should only be done after ensuring the client's safety and stability. Applying a sterile dressing (Option C) is also important but not as critical as informing the healthcare provider of the medication history.

2. When performing an assessment of a child with recurrent abdominal pain (RAP), what symptom is the child most likely to experience?

• A. Increased temperature
• B. Constipation
• C. Right quadrant pain
• D. Exercise-associated pain

Correct answer: B

Rationale: When assessing a child with recurrent abdominal pain (RAP), constipation is a common symptom. Children with RAP often experience periumbilical pain that is unrelated to eating, defecation, or exercise. While increased temperature, right quadrant pain, and exercise-associated pain can occur in various conditions, they are not typically associated with RAP in children.

3. A client who had surgery yesterday is becoming increasingly anxious. The client’s respiratory rate has increased to 38 breaths/minute. The client has a nasogastric tube to low intermittent suction with 500 ml of yellow-green drainage over the last four hours. The client's arterial blood gases (ABGs) indicate a decreased CO2 and an increased serum pH. Which serum laboratory value should the nurse monitor first?

• A. Electrolytes.
• B. Creatinine.
• C. Blood urea nitrogen.
• D. Glucose.

Correct answer: A

Rationale: The correct answer is A, Electrolytes. In this scenario, the client is at risk for metabolic alkalosis due to the loss of gastric secretions through the nasogastric tube. Monitoring electrolytes is crucial to assess the levels of sodium, potassium, chloride, and bicarbonate, which are important in maintaining the acid-base balance of the body. Changes in these electrolyte levels can provide valuable information about the client's fluid status and acid-base balance. Creatinine, blood urea nitrogen, and glucose levels are important parameters to monitor in different situations but are not the priority in this case of potential metabolic alkalosis.

4. A new mother asks the clinic nurse if she must continue giving her baby nystatin for thrush since the white lesions on his tongue have disappeared. What response by the nurse is most appropriate?

• A. No. When the lesions have disappeared, you may stop the nystatin.
• B. Yes. You should continue it for the full 7 days.
• C. No. Thrush is a self-limiting disorder, and nystatin is given for complete treatment.
• D. Yes. The medication should be refilled for a second week of therapy.

Correct answer: B

Rationale: The correct answer is B because nystatin should be given for the full 7 days even if the lesions are no longer present. Continuing the treatment for the prescribed duration ensures complete eradication of the fungal infection. Choice A is incorrect as stopping the medication prematurely may lead to the reoccurrence of thrush. Choice C is inaccurate as nystatin is not just for comfort but for effective treatment. Choice D is incorrect as refilling the medication for a second week without medical advice may lead to unnecessary prolonged use and potential side effects.

5. What are the clinical manifestations of otitis media?

• A. Earache, wheezing, vomiting
• B. Coughing, rhinorrhea, headache
• C. Fever, irritability, pulling on ear
• D. Wheezing, cough, drainage in ear canal

Correct answer: C

Rationale: The correct answer is C: Fever, irritability, pulling on the ear. Clinical manifestations of otitis media commonly include fever, irritability, and children may show signs of pulling or rubbing their ears. Choices A, B, and D are incorrect. Choice A includes wheezing and vomiting, which are not typical symptoms of otitis media. Choice B includes coughing, rhinorrhea, and headache, which are more commonly associated with upper respiratory infections rather than otitis media. Choice D includes wheezing, cough, and drainage in the ear canal, which are not typical clinical manifestations of otitis media.

Similar Questions