Nursing Elites

1. What is the primary function of neutrophils?

• A. Heparin secretion
• B. Transport oxygen
• C. Phagocytotic action
• D. Antibody formation

Correct answer: C

Rationale: The correct answer is C: Phagocytotic action. Neutrophils are key components of the immune system, primarily involved in the phagocytosis of bacteria and other pathogens. Choice A, Heparin secretion, is incorrect as heparin is primarily secreted by mast cells and basophils. Choice B, Transport oxygen, is incorrect as this is mainly the function of red blood cells. Choice D, Antibody formation, is incorrect as antibody production is primarily carried out by B lymphocytes.

2. What is the priority nursing action during the immediate postoperative period for a client who just underwent a coronary artery bypass graft?

• A. Monitor for signs of infection
• B. Ensure the client is pain-free
• C. Assess for bleeding and arrhythmias
• D. Maintain a patent airway

Correct answer: D

Rationale: Maintaining a patent airway is the priority nursing action during the immediate postoperative period for a client who just underwent a coronary artery bypass graft. This is crucial to ensure adequate oxygenation, especially in the early recovery phase. Monitoring for signs of infection, ensuring the client is pain-free, and assessing for bleeding and arrhythmias are important aspects of postoperative care but maintaining a clear airway takes precedence in this scenario to prevent hypoxia and respiratory compromise. In the immediate postoperative period, maintaining a patent airway is essential to prevent complications such as airway obstruction, hypoxia, and respiratory distress, which are critical in ensuring the client's safety and recovery.

3. The nurse is preparing a client for discharge after a major surgical procedure. What is the priority instruction to include in the discharge teaching?

• A. Signs of infection to monitor for
• B. Pain management techniques
• C. Activity restrictions and safety measures
• D. All of the above

Correct answer: D

Rationale: The correct answer is D: All of the above. Providing comprehensive discharge instructions covering signs of infection to monitor for, pain management techniques, activity restrictions, and safety measures is crucial after a major surgical procedure. Each of these components plays a vital role in the client's recovery and well-being. It is important for the client to understand how to identify signs of infection, manage pain effectively, and adhere to activity restrictions to prevent complications and ensure a smooth recovery process. While each instruction is important on its own, combining all aspects into the discharge teaching ensures that the client has a holistic understanding of their post-operative care, empowering them to take charge of their health and know when to seek further assistance if needed. Choices A, B, and C are essential components of discharge teaching and should all be included to provide the client with comprehensive care instructions.

4. Which client is at the highest risk for developing pressure ulcers?

• A. A 50-year-old client with a fractured femur
• B. A 30-year-old client with diabetes mellitus
• C. A 65-year-old client with limited mobility
• D. A 70-year-old client with a history of stroke

Correct answer: C

Rationale: Clients with limited mobility are at the highest risk for developing pressure ulcers due to prolonged pressure on specific areas of the body. This constant pressure can lead to tissue damage and ultimately result in pressure ulcers. While age and medical conditions such as diabetes and a history of stroke can contribute to the risk of pressure ulcers, limited mobility is the most significant factor as it directly affects the ability to shift positions and relieve pressure on vulnerable areas of the body. Therefore, the 65-year-old client with limited mobility is at the highest risk compared to the other clients. The 50-year-old client with a fractured femur may have limited mobility due to the injury, but it is temporary and may not be as prolonged as chronic limited mobility. The 30-year-old client with diabetes mellitus and the 70-year-old client with a history of stroke are at risk for developing pressure ulcers, but their conditions do not directly impact their ability to shift positions and alleviate pressure like limited mobility does.

5. The healthcare provider is preparing to administer a 1.2mL injection to a 4-year-old. Which is the best site to administer an IM injection?

• A. Vastus Lateralis
• B. Radial artery
• C. Dorsogluteal
• D. Rectus femoris

Correct answer: A

Rationale: The correct answer is A, Vastus Lateralis. The vastus lateralis site is recommended for IM injections in small children due to its large muscle mass, making it suitable for injections in pediatric patients. Choices B, C, and D are incorrect. The radial artery is not a site for IM injections; it is a site for arterial puncture. The dorsogluteal site is not recommended for children due to potential risks, such as injury to the sciatic nerve. The rectus femoris is not typically used for IM injections in children, as other sites like the vastus lateralis are more commonly preferred.

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