Nursing Elites

1. A 4-year-old child falls off a tricycle and is admitted for observation. How can the nurse best facilitate the child's cooperation during the assessment?

• A. Ask the parent to hold the child during the assessment.
• B. Allow the child to play with a syringe without a needle.
• C. Ask the child to blow out the penlight as if to simulate success.
• D. Explain the function of each organ during the assessment.

Correct answer: C

Rationale: Engaging the child in blowing out the penlight simulates play and can reduce fear, helping with cooperation during the assessment. Choice A is not recommended as it may increase anxiety by separating the child from the parent. Choice B is not appropriate as it involves playing with a syringe, which may not be safe or suitable. Choice D is not ideal for a 4-year-old child as understanding organ functions may be beyond their developmental level.

2. An unlicensed assistive personnel (UAP) reports a weak pulse of 44 beats per minute in a client. What action should the charge nurse implement?

• A. Have the UAP recheck the pulse and report back.
• B. Have a licensed practical nurse (LPN) assess the client for apical-radial pulse deficit.
• C. Call the healthcare provider for further instructions.
• D. Immediately call the healthcare provider and prepare for transfer to critical care.

Correct answer: B

Rationale: The correct action is to have a licensed practical nurse (LPN) assess the client for an apical-radial pulse deficit. This assessment can provide further information about the client’s cardiovascular status and help determine if further intervention is necessary. Having the UAP recheck the pulse may delay appropriate assessment and intervention. Calling the healthcare provider for further instructions may not be necessary at this point unless the LPN assessment indicates a need for it. Immediately transferring the client to critical care without further assessment is not warranted based solely on the initial report of a weak pulse.

3. A client is admitted with diabetic ketoacidosis (DKA). Which laboratory result would the nurse expect to find in this client?

• A. pH level of 7.45
• B. Serum calcium of 15 mg/dL
• C. Blood glucose of 450 mg/dL
• D. Sodium level of 120 mEq/L

Correct answer: C

Rationale: Clients with diabetic ketoacidosis typically present with elevated blood glucose levels, often above 300 mg/dL. This high blood glucose level, along with other symptoms, helps confirm the diagnosis of DKA. A pH level of 7.45 would be indicative of alkalosis, not the acidosis seen in DKA. A serum calcium level of 15 mg/dL is significantly elevated and is not a typical finding in DKA. A sodium level of 120 mEq/L indicates hyponatremia, which is not a characteristic laboratory finding in DKA.

4. A client with heart failure is prescribed spironolactone. What is the nurse's priority intervention?

• A. Monitor the client's potassium levels closely.
• B. Assess for signs of hyperkalemia.
• C. Instruct the client to increase intake of potassium-rich foods.
• D. Increase the client’s fluid intake to prevent dehydration.

Correct answer: B

Rationale: The correct answer is B: Assess for signs of hyperkalemia. Spironolactone is a potassium-sparing diuretic, which can cause hyperkalemia (high potassium levels). Therefore, the nurse's priority intervention should be to assess the client for signs of hyperkalemia, such as muscle weakness, fatigue, and potentially dangerous cardiac arrhythmias. Monitoring potassium levels closely (choice A) is important but assessing for signs of hyperkalemia takes precedence. Instructing the client to increase intake of potassium-rich foods (choice C) can exacerbate hyperkalemia in this case. Increasing the client’s fluid intake to prevent dehydration (choice D) is not directly related to the potential side effect of spironolactone.

5. An adult client with a broken femur reports muscle spasms. What action should the nurse implement while awaiting surgery?

• A. Check the client's most recent electrolyte levels.
• B. Administer a PRN dose of muscle relaxant.
• C. Reduce the weight on the traction device.
• D. Encourage oral fluid intake to relieve muscle tension.

Correct answer: D

Rationale: The correct action for the nurse to implement while awaiting surgery for a client with muscle spasms due to a broken femur is to encourage oral fluid intake to relieve muscle tension. Dehydration can exacerbate muscle spasms, so increasing fluid intake can help alleviate them. Checking electrolyte levels may not directly address muscle spasms in this situation. Administering a muscle relaxant should be based on a healthcare provider's prescription, and traction weight adjustments should only be made by the provider overseeing the client's care.

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