Nursing Elites

1. Which laboratory finding should the nurse expect to see in a child with acute rheumatic fever?

• A. Thrombocytopenia
• B. Polycythemia
• C. Decreased ESR
• D. Positive ASO titer

Correct answer: D

Rationale: The correct answer is D: Positive ASO titer. A positive ASO titer indicates recent streptococcal infection, which is associated with acute rheumatic fever. Thrombocytopenia (choice A) is not a typical laboratory finding in acute rheumatic fever. Polycythemia (choice B) refers to an increased red blood cell count, which is not typically seen in acute rheumatic fever. Decreased ESR (choice C) is not a common laboratory finding in acute rheumatic fever; in fact, ESR is often elevated in inflammatory conditions like rheumatic fever.

2. When entering a client’s room to administer an 0900 IV antibiotic, the nurse finds that the client is engaged in sexual activity with a visitor. Which actions should the nurse implement?

• A. Ignore the behavior and administer the IV antibiotic
• B. Tell the client to stop the inappropriate behavior
• C. Leave the room and close the door quietly
• D. Complete an unusual occurrence report

Correct answer: C

Rationale: The correct action for the nurse in this situation is to leave the room and close the door quietly. This response respects the client's privacy, maintains professionalism, and avoids interrupting the client's personal moment. Choice A is incorrect because ignoring the behavior is not appropriate and may invade the client's privacy further. Choice B is incorrect as it can embarrass the client and the visitor, breaching their privacy and dignity. Choice D is also incorrect as the immediate priority is to respect the client's privacy and address the situation discreetly.

3. The nurse is caring for a client with a tracheostomy. Which action should the nurse perform when suctioning the tracheostomy tube?

• A. Increase wall suction while removing the suction catheter
• B. Instill 10 ml of sterile saline into the tracheostomy tube before applying continuous suction
• C. Suction the client’s oropharynx after tracheal suctioning
• D. Insert the suction catheter into the trachea, and apply intermittent suction with removal of the catheter

Correct answer: D

Rationale: When suctioning a tracheostomy tube, it is essential to insert the suction catheter into the trachea and apply intermittent suction with removal of the catheter. This technique helps prevent damage to the trachea and reduces discomfort for the client. Choice A is incorrect because increasing wall suction with the removal of the suction catheter can cause trauma to the tracheal mucosa. Choice B is incorrect because instilling saline into the tracheostomy tube before suctioning is not recommended as it can lead to complications. Choice C is incorrect as oropharyngeal suctioning should be done before tracheal suctioning to prevent the risk of aspiration.

4. Which client requires careful nursing assessment for signs and symptoms of hypomagnesemia?

• A. A young adult client with intractable vomiting from food poisoning
• B. A client who developed hyperparathyroidism in late adolescence
• C. A middle-aged male client in renal failure following an unsuccessful kidney transplant
• D. A female client who is overzealous with her intake of simple carbohydrates

Correct answer: A

Rationale: The correct answer is A. Vomiting can lead to significant loss of magnesium, causing hypomagnesemia. In this scenario, the young adult client with intractable vomiting from food poisoning is at higher risk of developing hypomagnesemia due to the loss of magnesium through vomiting. Choices B, C, and D are less likely to present with hypomagnesemia. Hyperparathyroidism (B) is associated with hypercalcemia, renal failure (C) can lead to hypermagnesemia, and overconsumption of simple carbohydrates (D) is not directly linked to magnesium imbalances.

5. Which type of wound would most likely require immediate intervention by the healthcare provider?

• A. Laceration
• B. Abrasion
• C. Contusion
• D. Ulceration

Correct answer: A

Rationale: A laceration would most likely require immediate intervention by the healthcare provider due to its deeper tissue damage, significant bleeding, and higher risk of infection compared to abrasions, contusions, and ulcerations. Lacerations often need prompt attention to control bleeding, clean the wound, and reduce the risk of infection. Abrasions are superficial wounds that usually do not require urgent attention as they tend to heal well on their own with basic wound care. Contusions are bruises that typically resolve on their own without immediate intervention. Ulcerations are open sores that may require intervention but not necessarily immediate action unless complicated by infection or other issues.

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