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. The nurse is assessing a client who has a prescription for digoxin (Lanoxin). Which finding indicates that the client is at risk for digoxin toxicity?

• A. Heart rate of 60 beats per minute
• B. Blood pressure of 120/80 mm Hg
• C. Respiratory rate of 18 breaths per minute
• D. Serum potassium level of 3.0 mEq/L

Correct answer: D

Rationale: A low serum potassium level increases the risk of digoxin toxicity. Digoxin toxicity is more likely to occur in individuals with low potassium levels because potassium is crucial for proper heart function. A heart rate of 60 beats per minute, blood pressure of 120/80 mm Hg, and respiratory rate of 18 breaths per minute are within normal ranges and do not directly indicate an increased risk of digoxin toxicity.

3. The nurse is preparing a client for discharge who has a prescription for enoxaparin (Lovenox) self-administration. What information is most important for the nurse to provide the client about this medication?

• A. Self-administration techniques for subcutaneous injection
• B. Avoiding foods high in vitamin K
• C. Signs of bleeding to report to the healthcare provider
• D. Proper disposal of used syringes

Correct answer: A

Rationale: Teaching the client about self-administration techniques for subcutaneous injection is crucial for safe and effective use of enoxaparin. Option A is the correct answer as it directly addresses the client's need to know how to properly administer the medication. Options B, C, and D are important aspects of care but are not the most critical information needed for the client's self-administration of enoxaparin.

4. At a community health fair, a 50-year-old woman tells the nurse that she has an annual physical exam that includes a clinical breast exam and an annual mammogram. How should the nurse respond?

• A. Encourage the woman to explore her fears about breast cancer.
• B. Ask the woman if she also performs monthly breast self-exams.
• C. Commend the woman for adhering to the recommended cancer detection guidelines.
• D. Advise the woman that mammograms are only needed every two years at her age.

Correct answer: B

Rationale: The correct answer is B. Monthly breast self-exams are essential for early detection of breast cancer. While annual clinical breast exams and mammograms are important, monthly self-exams enhance early detection by helping women become familiar with their breasts and notice any changes. Choice A is incorrect as it does not address the importance of self-exams. Choice C is incorrect as it prematurely commends without ensuring the woman is conducting self-exams. Choice D is incorrect as it provides inaccurate information about the frequency of mammograms needed.

5. The nurse observes a client in a wheelchair with a vest restraint in place. What nursing intervention is most important for the nurse to implement?

• A. Assess the need for continued restraint
• B. Check the client for urinary incontinence
• C. Determine skin integrity under the vest
• D. Perform range-of-motion exercises on extremities

Correct answer: A

Rationale: The correct answer is to assess the need for continued restraint. This is the most important nursing intervention as it ensures the client's safety and autonomy. Checking for urinary incontinence (Choice B) may be important but is not the priority in this situation. Determining skin integrity under the vest (Choice C) is essential but not as crucial as assessing the need for continued restraint. Performing range-of-motion exercises (Choice D) is important for client mobility but not the priority when a restraint is in place.

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