Nursing Elites

1. What is the first action the nurse should take when treating a 6-year-old child who stepped on a rusty nail?

• A. Cleanse the foot with soap and water
• B. Instruct the parent about tetanus boosters
• C. Apply a sterile dressing and refer for a tetanus booster
• D. Elevate the foot and wrap in a compression bandage

Correct answer: B

Rationale: The correct first action when a 6-year-old child steps on a rusty nail is to instruct the parent about tetanus boosters. This is important because stepping on a rusty nail increases the risk of tetanus infection. Choice A is incorrect as cleansing the foot comes after addressing the tetanus risk. Choice C is not the first action and should be done after addressing the immediate risk of tetanus. Choice D is not necessary as the priority is to prevent tetanus infection.

2. A client with cirrhosis is prescribed spironolactone to manage ascites. Which serum laboratory value is most important for the nurse to monitor?

• A. Sodium
• B. Calcium
• C. Magnesium
• D. Potassium

Correct answer: D

Rationale: The correct answer is D: Potassium. Spironolactone is a potassium-sparing diuretic, which can lead to hyperkalemia. Monitoring potassium levels is crucial to prevent complications like cardiac arrhythmias. Choices A, B, and C are incorrect because sodium, calcium, and magnesium levels are not directly affected by spironolactone use for managing ascites in cirrhosis.

3. A client with acute kidney injury has an elevated creatinine level. What is the nurse's priority intervention?

• A. Administer diuretics as prescribed.
• B. Prepare the client for dialysis.
• C. Restrict the client’s fluid intake.
• D. Notify the healthcare provider immediately.

Correct answer: B

Rationale: The correct answer is B: Prepare the client for dialysis. Clients with acute kidney injury and elevated creatinine may require dialysis to support kidney function and remove waste products from the blood. Preparing for dialysis ensures timely intervention in preventing further complications. Administering diuretics (Choice A) may worsen the client's condition by further compromising kidney function. Restricting fluid intake (Choice C) may be necessary in some cases, but it is not the priority over preparing for dialysis. Notifying the healthcare provider (Choice D) is important, but the immediate priority is to prepare for dialysis to address the acute kidney injury and elevated creatinine level.

4. A child is brought to the emergency department after ingesting an unknown quantity of acetaminophen. What is the most important action for the nurse to take?

• A. Assess the child's level of consciousness.
• B. Prepare to administer activated charcoal.
• C. Notify the poison control center.
• D. Obtain an order for serum acetaminophen levels.

Correct answer: D

Rationale: Obtaining serum acetaminophen levels is critical in determining the level of toxicity and guiding treatment. It helps to assess the risk of hepatotoxicity and determine the need for antidotal therapy with N-acetylcysteine. Assessing the child's level of consciousness (Choice A) is important but obtaining serum acetaminophen levels takes precedence as it directly guides the specific treatment required. Activated charcoal (Choice B) is not routinely used in acetaminophen poisoning. While notifying the poison control center (Choice C) is important, obtaining serum acetaminophen levels should be the immediate action to assess the child's condition and guide treatment.

5. A client who recently underwent a tracheostomy is being prepared for discharge to home. Which instructions are most important for the nurse to include in the discharge plan?

• A. Teach signs of infection
• B. Teach tracheal suctioning techniques
• C. Educate on humidifying air
• D. Discuss the use of a speaking valve

Correct answer: B

Rationale: The correct answer is B: Teach tracheal suctioning techniques. Tracheal suctioning is crucial for maintaining a clear airway in clients with a tracheostomy. Without proper suctioning, secretions can accumulate and cause airway obstruction or respiratory infections. Educating the client on how to perform suctioning safely is a priority for discharge planning. Choices A, C, and D are important aspects of tracheostomy care, but teaching tracheal suctioning techniques takes precedence due to its direct impact on airway patency and preventing complications.

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