Nursing Elites

1. What is the most critical initial intervention for a client who is actively seizing?

• A. Restrain the client to prevent injury
• B. Insert an oral airway
• C. Turn the client to the side
• D. Apply soft restraints to the wrists

Correct answer: C

Rationale: The most critical initial intervention for a client who is actively seizing is to turn the client to the side. This action helps maintain an open airway and prevents aspiration during a seizure. Restrain the client to prevent injury (Choice A) is incorrect because restraining a client during a seizure can lead to injury. Inserting an oral airway (Choice B) is not recommended as it can cause injury and is not necessary during an active seizure. Applying soft restraints to the wrists (Choice D) is also not recommended as it can lead to harm and does not address the immediate airway management needed during a seizure.

2. A male client with muscular dystrophy fell in his home and is admitted with a right hip fracture. His right foot is cool, with palpable pedal pulses. Lungs are coarse with diminished bibasilar breath sounds. Vital signs are temperature 101 degrees F, heart rate 128 beats/minute, respirations 28 breaths/minute, and blood pressure 122/82. Which intervention is most important for the nurse to implement first?

• A. Obtain oxygen saturation level.
• B. Encourage incentive spirometry.
• C. Assess lower extremity circulation
• D. Administer PRN oral antipyretic.

Correct answer: D

Rationale: Administering an antipyretic is the most important intervention. The client presents with an elevated temperature, tachycardia, and tachypnea, indicating a fever. Lowering the temperature with an antipyretic is crucial to prevent complications like dehydration, altered mental status, and increased oxygen demand. While assessing lower extremity circulation and oxygen saturation are important, addressing the elevated temperature takes priority in this scenario. Incentive spirometry may be beneficial but is not the priority compared to managing the fever.

3. The mother of a child who has been diagnosed with varicella asks the nurse when the child can return to school. When is the child no longer contagious?

• A. When the fever dissipates
• B. After the incubation period
• C. When the lesions have healed
• D. When the lesions are crusted over

Correct answer: D

Rationale: The correct answer is D: 'When the lesions are crusted over.' Varicella is no longer contagious once the lesions are dry and crusted. This stage indicates that the active viral shedding has significantly decreased, reducing the risk of transmission. Choice A, 'When the fever dissipates,' is incorrect because the presence of fever does not necessarily correlate with the contagiousness of varicella. Choice B, 'After the incubation period,' is incorrect as the incubation period occurs before the onset of symptoms and is not relevant to determining contagiousness. Choice C, 'When the lesions have healed,' is incorrect as healed lesions can still be contagious if they are not crusted over.

4. Following a bout of diarrhea, which foods should be offered to the school-age child?

• A. Apricots and peaches
• B. Chocolate milk
• C. Applesauce and milk
• D. Bananas and rice

Correct answer: D

Rationale: After rehydration, it is important to offer foods that are nonirritating to the bowel to the child. Bananas and rice are considered the best options as they are least likely to irritate the gastrointestinal tract. Apricots, peaches, and applesauce are fruits that may cause GI irritation, while milk, including chocolate milk, can also be irritating to the bowel. Therefore, the optimal choice for a child recovering from diarrhea would be bananas and rice.

5. A male client with diabetes mellitus is transferred from the hospital to a rehabilitation facility following treatment for a stroke resulting in right hemiplegia. He tells the nurse that his feet are always uncomfortably cool at night, preventing him from falling asleep. Which action should the nurse implement?

• A. Provide a warming pad for his feet
• B. Medicate the client with a prescribed sedative.
• C. Use a bed cradle to keep the covers off his feet.
• D. Place warm blankets next to the client's feet.

Correct answer: D

Rationale: Placing warm blankets next to the client's feet is the most appropriate action to provide warmth and comfort. This method is safe and effective in addressing the client's complaint of uncomfortably cool feet at night. Providing a warming pad (Choice A) may pose a risk of burns or injury, especially for a client with decreased sensation due to diabetes. Mediating the client with a sedative (Choice B) does not address the underlying issue of cool feet and may not be necessary. Using a bed cradle (Choice C) to hold the covers off the feet does not directly address the client's need for warmth and comfort.

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