Nursing Elites

1. In a mass casualty scenario at a child day care center, which child would the triage nurse prioritize for treatment last?

• A. An infant with intermittent bulging anterior fontanel between crying episodes
• B. A toddler with severe deep abrasions covering over 98% of the body
• C. A preschooler with 1 lower leg fracture and the other leg with an upper leg fracture
• D. A school-age child with singed eyebrows and hair on the arms

Correct answer: B

Rationale: In a mass casualty scenario, the triage nurse would prioritize the toddler with severe deep abrasions covering over 98% of the body for treatment last. This child is categorized as 'expectant' due to the extensive injuries, which are unlikely to be survivable even with immediate treatment. The other choices describe injuries that are serious but have a higher likelihood of survival with appropriate and timely intervention. The infant with an intermittent bulging anterior fontanel may have increased intracranial pressure requiring urgent evaluation, the preschooler with leg fractures can be stabilized and treated effectively, and the school-age child with singed hair likely has superficial burns which can be managed promptly.

2. A self-sufficient bedridden patient is unable to reach all body parts. Which type of bath will the nurse assign to the nursing assistive personnel?

• A. Bag bath
• B. Sponge bath
• C. Partial bed bath
• D. Complete bed bath

Correct answer: C

Rationale: The correct answer is a partial bed bath (Choice C). A partial bed bath involves washing body parts that the patient cannot reach on their own, such as the back. It also includes providing assistance with a backrub to promote circulation and skin integrity. In this scenario, where the patient is bedridden and unable to reach all body parts, a partial bed bath is the most appropriate as it focuses on areas the patient cannot clean themselves. Choices A, B, and D are incorrect because a bag bath involves using premoistened disposable cloths for bathing, a sponge bath involves using a basin of water and a sponge for cleansing, and a complete bed bath involves washing the entire body, including areas the patient can reach, which are not necessary in this case.

3. A client with an NG tube is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first?

• A. Rinse the feeding bag with water between feedings
• B. Tell the client to keep the head of the bed elevated at least 30°
• C. Make sure the enteral formula is at room temperature
• D. Wipe the top of the formula can with alcohol

Correct answer: B

Rationale: The correct answer is to tell the client to keep the head of the bed elevated at least 30°. Elevating the head of the bed prevents aspiration of the enteral formula, which is a priority in caring for a client with an NG tube. This action helps in reducing the risk of complications such as pneumonia. Choices A, C, and D are incorrect. While rinsing the feeding bag, ensuring the enteral formula temperature, and maintaining cleanliness are important aspects of enteral feeding care, the priority is to prevent aspiration by keeping the head of the bed elevated. These actions can be implemented after ensuring the client's safety by maintaining the correct bed position.

4. The nurse observes an UAP positioning a newly admitted client who has a seizure disorder. The client is supine, and the UAP is placing soft pillows along the side rails. Which action should the nurse implement?

• A. Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows
• B. Ensure that the UAP has placed pillows effectively to protect the client
• C. Ask the UAP to use some pillows to prop the client in a side-lying position
• D. Assume responsibility for placing the pillows while the UAP completes another task

Correct answer: A

Rationale: Using soft blankets to secure to the side rails provides better protection during a seizure as they are more secure and less likely to shift compared to pillows. This action helps prevent injury to the client by minimizing the risk of falling or hitting the side rails during a seizure. Choices B and C do not address the issue of using more secure materials. Choice D is inappropriate as it is important for the nurse to ensure the safety and well-being of the client by using the most appropriate protective measures.

5. A client with chronic renal failure selects scrambled eggs for breakfast. What action should the LPN/LVN take?

• A. Commend the client for selecting a high biological value protein.
• B. Remind the client that protein in the diet should be avoided.
• C. Suggest that the client also select orange juice to promote absorption.
• D. Encourage the client to attend classes on dietary management of chronic renal failure.

Correct answer: A

Rationale: The correct action is to commend the client for selecting a high biological value protein, as scrambled eggs provide a good protein source for clients with chronic renal failure. Protein is essential for maintaining muscle mass and overall health in these clients. Reminding the client to avoid protein is incorrect as it may lead to protein-energy malnutrition, which is a common concern in chronic renal failure. Suggesting orange juice for absorption is not relevant to the situation, as protein absorption is not a primary concern in this context. Encouraging the client to attend classes on dietary management of chronic renal failure is important for overall education but is not the immediate action needed in response to the client's breakfast choice.

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