Nursing Elites

1. A 3-year-old boy is brought to the emergency center with dysphagia, drooling, a fever of 102°F, and stridor. Which intervention should the nurse implement first?

• A. Place the child in a mist tent
• B. Obtain a sputum culture
• C. Prepare for an emergent tracheostomy
• D. Examine the child's oropharynx and report the findings to the healthcare provider

Correct answer: A

Rationale: In a 3-year-old boy presenting with dysphagia, drooling, fever, and stridor, the priority intervention should be to place the child in a mist tent. This intervention helps alleviate respiratory distress, providing immediate relief. Options B, C, and D are not as urgent as ensuring the child's airway is managed effectively. Obtaining a sputum culture, preparing for a tracheostomy, and examining the oropharynx can be done after stabilizing the child's respiratory status.

2. A 20-year-old male client is diagnosed with Ewing's sarcoma following examination for a knee injury. Which instruction is most important for the nurse to provide the client?

• A. Take analgesics regularly to reduce the pain
• B. Notify the healthcare provider if the swelling worsens
• C. Avoid weight-bearing until the injury heals
• D. Seek treatment for the sarcoma immediately

Correct answer: D

Rationale: The correct answer is to instruct the client to seek treatment for the sarcoma immediately. Ewing's sarcoma is an aggressive cancer, and prompt treatment is crucial for improving prognosis. Option A is incorrect because while pain management is important, addressing the underlying cause (sarcoma) is the priority. Option B is not as critical as seeking treatment for the sarcoma itself. Option C is not the most important instruction as the primary concern is addressing the cancer diagnosis.

3. The nurse is planning care for a client who is receiving phenytoin (Dilantin) for seizure control. Which intervention is most important to include in this client’s plan of care?

• A. Monitor serum calcium levels
• B. Obtain a baseline electrocardiogram
• C. Implement seizure precautions
• D. Encourage a low-protein diet

Correct answer: C

Rationale: The correct answer is to implement seizure precautions. Phenytoin is an antiepileptic medication used for seizure control. Seizure precautions are crucial for clients taking this medication to ensure their safety during a seizure episode. Monitoring serum calcium levels (Choice A) is not directly related to phenytoin therapy. Obtaining a baseline electrocardiogram (Choice B) is important for some medications but not the priority for a client on phenytoin. Encouraging a low-protein diet (Choice D) is not specifically indicated for clients on phenytoin and is not the most important intervention.

4. The nurse is administering total parenteral nutrition (TPN) via a central line at 75 ml/hour to a client who had a bowel resection 4 days ago. Which laboratory finding requires the most immediate intervention by the nurse?

• A. Blood glucose of 140 mg/dL
• B. White blood cell count of 8000/mm³
• C. Serum potassium of 3.8 mEq/L
• D. Serum calcium of 7.8 mg/dL

Correct answer: D

Rationale: The correct answer is D. A serum calcium level of 7.8 mg/dL requires immediate intervention due to the risk of hypocalcemia. Hypocalcemia can lead to serious complications such as tetany, seizures, and cardiac arrhythmias. The other laboratory findings are within normal limits or slightly elevated, which do not pose an immediate threat to the client's health in this scenario.

5. When administering an intramuscular injection containing 3 ml of a painful medication, which intervention should the nurse implement?

• A. Instill the medication quickly
• B. Insert the needle slowly
• C. Select a large, deep muscle mass
• D. Use a short, small gauge needle

Correct answer: C

Rationale: The correct answer is C: Select a large, deep muscle mass. When administering an intramuscular injection with a painful medication volume of 3 ml, selecting a large and deep muscle mass is crucial. This intervention reduces discomfort for the patient and ensures proper absorption of the medication. Choice A is incorrect because instilling the medication quickly can increase discomfort. Choice B is incorrect as inserting the needle slowly may prolong the discomfort. Choice D is incorrect as using a short, small gauge needle may not be suitable for delivering 3 ml of medication effectively into the muscle.

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