Nursing Elites

1. A 10-year-old is admitted to the orthopedic unit with a diagnosis of slipped femoral capital epiphysis (SFCE). What focus should the nurse include in this child’s plan of care?

• A. Ambulation with a walking cast.
• B. Pin and incision care after surgery.
• C. Use of injections for pain control.
• D. Administration of growth hormone.

Correct answer: B

Rationale: In the case of slipped femoral capital epiphysis, surgical intervention is often required. Post-surgery care is crucial to prevent complications such as infection and ensure proper healing. This care includes monitoring and managing pin and incision sites for signs of infection, promoting wound healing, and preventing postoperative complications. The focus on pin and incision care is essential for the child's recovery and overall well-being.

2. The healthcare provider is preparing to administer phytonadione to a newborn. Which statement made by the parents indicates understanding why the healthcare provider is administering this medication?

• A. Prevent hemorrhagic disorders.
• B. Help an immature liver.
• C. Improve insufficient dietary intake.
• D. Stimulate the immune system.

Correct answer: A

Rationale: The correct answer is A: 'Prevent hemorrhagic disorders.' Phytonadione (vitamin K) is administered to newborns to prevent hemorrhagic disease by promoting blood clotting. Newborns are born with low levels of vitamin K, which is essential for blood clotting, hence the administration to prevent hemorrhagic disorders. Choice B is incorrect because phytonadione is not given to help an immature liver but to supply vitamin K. Choice C is incorrect as phytonadione is not administered to improve dietary intake but to provide essential vitamin K. Choice D is incorrect as phytonadione does not stimulate the immune system but helps with blood clotting.

3. The client is 24 weeks gestation and reports increased thirst and urination. Which diagnostic test result should the nurse report to the healthcare provider?

• A. Hemoglobin A1C.
• B. Postprandial blood glucose test.
• C. Oral glucose tolerance test.
• D. Fasting blood glucose.

Correct answer: C

Rationale: An abnormal oral glucose tolerance test result is indicative of gestational diabetes. This test is crucial in diagnosing gestational diabetes as it evaluates how well the body processes glucose after a sugary drink. Reporting abnormal results promptly allows for timely intervention and management to ensure the well-being of both the mother and the baby. The other options are not the primary tests used to diagnose gestational diabetes. Hemoglobin A1C is not recommended for diagnosing gestational diabetes as it reflects long-term glucose control. Postprandial blood glucose and fasting blood glucose tests are not as sensitive as the oral glucose tolerance test for diagnosing gestational diabetes.

4. Upon arrival in the nursery, a newborn infant is breathing satisfactorily but appears dusky. What action should the LPN/LVN take first?

• A. Notify the healthcare provider immediately.
• B. Suction the infant's nares, then the oral cavity.
• C. Check the infant's oxygen saturation rate.
• D. Position the infant on the right side.

Correct answer: C

Rationale: The priority action in this scenario is to check the infant's oxygen saturation rate. This will provide crucial information on the infant's oxygen levels and the need for immediate oxygen therapy. Assessing oxygen saturation is essential in determining the severity of hypoxia and guiding further interventions to ensure adequate oxygenation. Option A is not the priority as immediate intervention related to oxygenation is needed before notifying the healthcare provider. Suctioning (Option B) may be necessary but should come after assessing oxygen saturation. Positioning the infant (Option D) does not address the immediate need to evaluate oxygen levels.

5. At 14-weeks gestation, a client arrives at the Emergency Center complaining of a dull pain in the right lower quadrant of her abdomen. The LPN/LVN obtains a blood sample and initiates an IV. Thirty minutes after admission, the client reports feeling a sharp abdominal pain and shoulder pain. Assessment findings include diaphoresis, a heart rate of 120 beats/minute, and a blood pressure of 86/48. Which action should the nurse implement next?

• A. Check the hematocrit results.
• B. Administer pain medication.
• C. Increase the rate of IV fluids.
• D. Monitor the client for contractions.

Correct answer: C

Rationale: The client's symptoms suggest hypovolemic shock, possibly due to an ectopic pregnancy. Increasing IV fluids is crucial to stabilize the client by improving blood pressure and perfusion. This intervention helps address the underlying issue of hypovolemia and supports the client's hemodynamic status, which takes priority in this emergent situation.

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