Nursing Elites

1. A child presents to the school nurse with left knee pain after suffering a fall on the playground. Which action should the nurse do first?

• A. Instruct the child to extend the affected knee
• B. Perform range of motion exercises on both knees
• C. Compare the appearance of the left knee to the right knee
• D. Have the child soak the affected knee in warm water

Correct answer: C

Rationale: Comparing the appearance of the left knee to the right knee is the most appropriate initial action as it provides a baseline for assessing any visible differences such as swelling, bruising, or deformities. This comparison helps the nurse identify any acute changes in the affected knee's appearance after the fall. Instructing the child to extend the affected knee (Choice A) may worsen the pain or cause further injury. Performing range of motion exercises on both knees (Choice B) could exacerbate the pain and should be avoided until a proper assessment is done. Having the child soak the affected knee in warm water (Choice D) is not the priority at this stage as assessing for any physical changes is more crucial.

2. The client develops a tension pneumothorax. Assessment is expected to reveal?

• A. Sudden hypertension and bradycardia
• B. Productive cough with yellow mucus
• C. Tracheal deviation and dyspnea
• D. Sudden development of profuse hemoptysis and weakness

Correct answer: C

Rationale: In a tension pneumothorax, the trachea deviates to the unaffected side due to increased pressure in the affected pleural space, causing respiratory distress. Dyspnea is a hallmark symptom as the lung on the affected side collapses, leading to difficulty in breathing. Sudden hypertension and bradycardia (Choice A) are not typical findings of tension pneumothorax. Productive cough with yellow mucus (Choice B) is more suggestive of respiratory infections rather than a tension pneumothorax. Sudden development of profuse hemoptysis and weakness (Choice D) is not characteristic of tension pneumothorax presentation.

3. Is head lag expected to be resolved by 4 months of age? Continuing head lag at 6 months of age may indicate?

• A. Dizziness and orthostatic hypotension.
• B. Nausea, vomiting, diarrhea, or constipation, and stomach cramps.
• C. Drowsiness, lethargy, and fatigue.
• D. Neuropathy and tingling in the extremities.

Correct answer: B

Rationale: Head lag is a developmental milestone that should be resolved by 4 months of age. Continuing head lag at 6 months of age may indicate potential developmental delays or muscle weakness. The correct answer, 'Nausea, vomiting, diarrhea, or constipation, and stomach cramps,' reflects symptoms that could be associated with developmental delays or underlying health conditions. Dizziness and orthostatic hypotension (Choice A) are unlikely to be directly related to head lag. Choices C and D present symptoms that are unrelated to the issue of continued head lag at 6 months of age.

4. A client goes to the Emergency Department with acute respiratory distress and the following arterial blood gases (ABGs): pH 7.35, PCO2 40 mmHg, PO2 63mmHg, HCO3 23, and oxygenation saturation (SAO2) 93%. Which of the following represents the best analysis of the etiology of these ABGs?

• A. tuberculosis (TB)
• B. pneumonia
• C. pleural effusion
• D. hypoxia

Correct answer: D

Rationale: A combined low PO2 and low SAO2 indicates hypoxia. The pH, PCO2, and HCO3 are normal. ABGs are not necessarily altered in TB or pleural effusion. In pneumonia, the PO2 and PCO2 might be low because hypoxia stimulates hyperventilation, but the best analysis in this case is hypoxia due to the combination of low PO2 and low SAO2.

5. When assessing a client in the Emergency Department whose membranes have ruptured, the nurse notes that the fluid is a greenish color. What is the cause of this greenish coloration?

• A. blood
• B. meconium
• C. hydramnios
• D. caput

Correct answer: B

Rationale: The correct answer is B: meconium. Greenish amniotic fluid passed when the fetus is in a cephalic (head) presentation might indicate fetal distress. A fetus in the breech presentation passes meconium due to compression on the intestinal tract. Choice A, blood, is incorrect as blood in the amniotic fluid would present as a different color. Choice C, hydramnios, refers to an excess of amniotic fluid and would not cause the greenish coloration. Choice D, caput, is swelling of a newborn's scalp and is not related to the color of the amniotic fluid.

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