Nursing Elites

1. Which techniques should be used to administer an intradermal (ID) injection for a Mantoux test to screen for tuberculosis (TB)? Select all that apply.

• A. Observe for an intradermal bleed after the antigen is injected
• B. Select an ID site using the volar surface of the forearm
• C. Use a 26 or 27-gauge needle with a length of 1/4 to 5/8 inches on a 1 ml calibrated syringe
• D. Ensure that the needle is inserted into the skin with the bevel up

Correct answer: A

Rationale: Observing for an intradermal bleed after the antigen is injected is a proper technique for an ID injection. This is important to confirm the correct placement of the injection. Choice B is correct because the recommended site for an ID injection for a Mantoux test is the volar surface of the forearm. Choice C is incorrect because the standard needle size for an ID injection is usually 26 or 27 gauge with a length of 1/4 to 5/8 inches, not 25 gauge with a length of 1/2 inch. Choice D is incorrect because the needle should be inserted into the skin with the bevel facing up, not down.

2. The nurse is assessing a 3-month-old infant who had a pylorotomy yesterday. This child should be medicated for pain based on which finding?

• A. Restlessness
• B. Clenched Fist
• C. Increased pulse rate
• D. Increased respiratory rate

Correct answer: A

Rationale: In infants, restlessness can be a significant indicator of discomfort or pain, necessitating appropriate pain management. While choices B, C, and D can also be associated with pain, restlessness is a more general and reliable indicator in this scenario. A clenched fist might indicate pain or distress, but it is not as specific as restlessness in assessing pain in infants. Increased pulse rate and respiratory rate can be influenced by various factors other than pain, making them less reliable indicators of pain in this context.

3. A young adult male who is being seen at the employee health care clinic for an annual assessment tells the nurse that his mother was diagnosed with schizophrenia when she was his age and that life with a schizophrenic mother was difficult indeed. Which response is best for the nurse to provide?

• A. Ask the client if he is worried about becoming schizophrenic at the age his mother was diagnosed.
• B. Encourage the client to seek genetic counseling to determine his risk for mental illness.
• C. Inform the client that his mother’s schizophrenia has affected his psychological development.
• D. Tell the client that mental illness has a familial predisposition so he should see a psychiatrist.

Correct answer: B

Rationale: Genetic counseling can help assess risk and provide guidance for the client’s concerns about potential hereditary conditions.

4. The nurse is assessing a client with Addison's disease who is weak, dizzy, disoriented, and has dry oral mucous membranes, poor skin turgor, and sunken eyes. Vital signs are blood pressure 94/44, heart rate 123 beats/minute, respiration 22 breaths/minute. Which intervention should the nurse implement first?

• A. Assess extremity strength and resistance
• B. Report a sodium level of 132 mEq/L or mmol/L (SI units)
• C. Measure and record the cardiac QRS complex
• D. Check current finger stick glucose

Correct answer: D

Rationale: The client’s symptoms suggest possible adrenal crisis or hypoglycemia. Checking glucose is a priority to rule out hypoglycemia, which requires immediate intervention. The client is presenting with symptoms indicative of hypoglycemia, which can be life-threatening if not promptly addressed. Assessing extremity strength, reporting sodium levels, or measuring the cardiac QRS complex are not the most urgent actions in this scenario.

5. Following morning care, a client with C-5 spinal cord injury who is sitting in a wheelchair becomes flushed and complains of a headache. Which intervention should the nurse implement first?

• A. Check for any kinks or obstructions in the client’s Foley tubing
• B. Assess the client’s blood pressure every 15 minutes
• C. Administer a prescribed PRN dose of hydralazine (Apresoline)
• D. Educate the client on recognizing symptoms of dysreflexia

Correct answer: B

Rationale: In a client with a C-5 spinal cord injury experiencing flushing and a headache, the priority intervention is to assess the client's blood pressure every 15 minutes. These symptoms could indicate autonomic dysreflexia, a potentially life-threatening condition. Assessing the blood pressure is crucial to identify and address this emergency situation promptly. Checking for kinks or obstructions in the Foley tubing (Choice A) is important but not the priority in this scenario. Administering hydralazine (Choice C) without knowing the blood pressure could be harmful as it may lead to a sudden drop in blood pressure. Educating the client on recognizing symptoms of dysreflexia (Choice D) is important for long-term management but is not the immediate action needed in this acute situation.

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