Nursing Elites

1. A child is injured on the school playground and appears to have a fractured leg. What action should the school nurse take first?

• A. Call for emergency transport to the hospital
• B. Immobilize the limb and joints above and below the injury
• C. Assess the child and the extent of the injury
• D. Apply cold compresses to the injured area

Correct answer: C

Rationale: The correct first action for the school nurse to take when a child is injured and appears to have a fractured leg is to assess the child and the extent of the injury. This initial assessment is crucial to determine the severity of the injury before proceeding with further interventions. Option A, calling for emergency transport, should only be done after assessing the extent of the injury. Option B, immobilizing the limb and joints, is important but should come after the initial assessment. Option D, applying cold compresses, is not recommended for suspected fractures as it can exacerbate swelling and pain.

2. When assessing a male client, the nurse finds that he is fatigued and is experiencing muscle weakness, leg cramps, and cardiac dysrhythmias. Based on these findings, the nurse plans to check the client's laboratory values to validate the existence of which condition?

• A. Hyperphosphatemia
• B. Hypocalcemia
• C. Hypermagnesemia
• D. Hypokalemia

Correct answer: D

Rationale: The symptoms of muscle weakness, leg cramps, and cardiac dysrhythmias are indicative of hypokalemia, a condition characterized by low potassium levels. Checking the client's laboratory values for potassium will help confirm this diagnosis. Hyperphosphatemia (Choice A) is an elevated phosphate level in the blood, which is not consistent with the symptoms described. Hypocalcemia (Choice B) is a low calcium level and typically presents with different symptoms than those mentioned in the scenario. Hypermagnesemia (Choice C) is an excess of magnesium in the blood and does not align with the symptoms of muscle weakness, leg cramps, and cardiac dysrhythmias observed in the client.

3. UAP has lowered the head of the bed to change the linens for a client who is bedridden. Which observation...most immediate intervention by the nurse?

• A. A feeding is infusing at 40 mL/hr through an enteral feeding tube.
• B. The urine meter attached to the urinary drainage bag is completely full.
• C. There is a large dependent loop in the client's urinary drainage tubing.
• D. Purulent drainage is present around the insertion site of the feeding tube.

Correct answer: D

Rationale: The correct answer is D. Purulent drainage around the insertion site of the feeding tube indicates an infection, which requires immediate attention. This may be a sign of a serious complication that needs prompt nursing intervention to prevent further complications or deterioration in the client's condition. Choices A, B, and C do not indicate an immediate threat to the client's health. While option A highlights the infusion rate of the feeding, it does not pose an immediate risk compared to the presence of purulent drainage indicating infection.

4. A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an assistive personnel (AP)?

• A. Assist the client with a partial bed bath
• B. Measure the client's BP after the nurse administers an antihypertensive medication
• C. Use a communication board to ask what the client wants for lunch
• D. Feed the client

Correct answer: A

Rationale: In this scenario, the nurse should assign the task of assisting the client with a partial bed bath to an assistive personnel (AP). APs are trained to provide basic care tasks like hygiene assistance. Options B, C, and D involve more complex tasks such as measuring BP, using a communication board for speech-impaired clients, and feeding, which require nursing judgment and skills beyond basic care. Therefore, these tasks should be performed by licensed nursing staff who can assess, communicate effectively, and address the specific medical and safety needs of the client.

5. Following major abdominal surgery, a client postoperative refuses to use the incentive spirometer. What is the nurse's priority?

• A. Determine the reason why the client is refusing to use the incentive spirometer.
• B. Insist that the client use the incentive spirometer.
• C. Administer pain medication to help the client use the spirometer.
• D. Document the refusal in the client’s medical record.

Correct answer: A

Rationale: The nurse's priority in this situation is to determine the reason why the client is refusing to use the incentive spirometer. By understanding the client's concerns or barriers, the nurse can address them effectively and encourage the client to use the spirometer for optimal postoperative recovery. Insisting that the client use the spirometer without understanding the underlying reason may lead to further resistance. Administering pain medication as a solution does not address the root cause of refusal and may not be necessary if pain is not the primary reason for refusal. Documenting the refusal is important but should come after understanding the client's perspective to provide appropriate care and follow-up.

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