Nursing Elites

1. Which symptom would indicate a complication after a subdural hematoma?

• A. Increased appetite
• B. Decreased level of consciousness
• C. High-pitched cry
• D. Bulging posterior fontanelle

Correct answer: B

Rationale: A bulging posterior fontanelle is a sign of increased intracranial pressure in infants, not a common symptom after a subdural hematoma. In the context of a subdural hematoma, a decreased level of consciousness is more indicative of a complication as it can be a sign of worsening brain function due to increased pressure on the brain from the collection of blood in the subdural space. Increased appetite and high-pitched cry are not typically associated with complications of a subdural hematoma.

2. A nurse is preparing to administer a rectal suppository to a school-age child. Which of the following actions should the nurse plan to take?

• A. Insert the suppository 1 cm into the rectum
• B. Insert the suppository 2 cm into the rectum
• C. Insert the suppository past the anal sphincters
• D. Insert the suppository using two fingers

Correct answer: C

Rationale: The correct answer is C: 'Insert the suppository past the anal sphincters.' When administering a rectal suppository, it is essential to insert it past the anal sphincters to ensure proper placement and absorption. Choices A and B are incorrect because the suppository should be inserted further than just 1 or 2 cm into the rectum to reach the optimal absorption site. Choice D is incorrect as using two fingers is not necessary and may cause discomfort to the child.

3. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following actions should the nurse take?

• A. Administer the TPN through a peripheral IV catheter.
• B. Check the client's capillary blood glucose level every 4 hours.
• C. Heat the TPN solution to room temperature before administering.
• D. Weigh the client every 3 days.

Correct answer: B

Rationale: The correct answer is to check the client's capillary blood glucose level every 4 hours. Clients receiving TPN are at risk for hyperglycemia, so regular monitoring of blood glucose levels is essential to detect and manage hyperglycemia promptly. Administering TPN through a peripheral IV catheter (Choice A) is incorrect as TPN should be given through a central venous catheter to prevent complications. Heating the TPN solution to room temperature (Choice C) is unnecessary and not a standard practice. Weighing the client every 3 days (Choice D) is important for monitoring fluid status but is not the priority action when caring for a client receiving TPN.

4. A nurse is reviewing the medical record of a client who has diabetes mellitus and is receiving insulin. Which of the following findings should the nurse report to the provider?

• A. Hemoglobin A1c of 6%
• B. Fasting blood glucose of 90 mg/dL
• C. Blood glucose of 200 mg/dL
• D. Blood glucose of 100 mg/dL

Correct answer: C

Rationale: A blood glucose level of 200 mg/dL indicates hyperglycemia and should be reported for potential insulin adjustment.

5. A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take?

• A. Wear sterile gloves when removing the old dressing
• B. Warm the irrigation solution to 40.5°C (105°F)
• C. Cleanse the wound from the center outwards
• D. Use a 20 mL syringe to irrigate the wound

Correct answer: C

Rationale: The correct action for the nurse to take when caring for a client with a prescription for wound irrigation is to cleanse the wound from the center outwards. This technique helps prevent contamination by pushing debris away from the wound rather than into it. Choice A is incorrect because wearing sterile gloves is important during wound care but not specifically mentioned for wound irrigation. Choice B is incorrect because warming the irrigation solution to a specific temperature is not a standard recommendation and can potentially harm the client. Choice D is incorrect because the size of the syringe may vary based on the wound size and depth, so using a 20 mL syringe is not a universal guideline.

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