Nursing Elites

1. A female client who was involved in a motor vehicle collision is admitted with a fractured left femur which is immobilized using a fracture traction splint in preparation for an open reduction internal fixation (ORIF). The nurse determines that her distal pulses are diminished in the left foot. Which interventions should the nurse implement? (Select all that apply)

• A. Verify pedal pulses using a doppler pulse device.
• B. Monitor left leg for pain, pallor, paresthesia, paralysis, pressure.
• C. Evaluate the application of the splint to the left leg.
• D.

Correct answer: C

Rationale: It is crucial for the nurse to evaluate the application of the splint to the left leg in a client with diminished distal pulses. This assessment helps ensure that the splint is not causing any compromise to circulation. Verifying pulses and monitoring for leg conditions are important interventions but do not directly address the issue with the splint application in this scenario, making them less relevant.

2. Which intervention should the nurse include in the plan of care for a client who has a chest tube due to hemothorax?

• A. Keep the arm and shoulder of the affected side immobile at all times.
• B. Encourage the client to breathe deeply and cough at frequent intervals.
• C. Maintain the pleura vac slightly above the chest level.
• D. Ensure there is no fluctuation in the water seal.

Correct answer: B

Rationale: Encouraging deep breathing and coughing is vital for a client with a chest tube due to hemothorax as it helps prevent atelectasis and promotes lung expansion. Keeping the arm and shoulder immobile (Choice A) is not necessary for chest tube management. Maintaining the pleura vac slightly above the chest level (Choice C) is incorrect as the pleura vac should be kept below the chest level to facilitate drainage. Ensuring no fluctuation in the water seal (Choice D) is important, but it is not the priority intervention when compared to promoting lung expansion through deep breathing and coughing.

3. Which dietary modification is most appropriate for a client with nephrotic syndrome?

• A. High protein, low sodium
• B. Low protein, high sodium
• C. High protein, high potassium
• D. Low protein, low sodium

Correct answer: D

Rationale: The most appropriate dietary modification for a client with nephrotic syndrome is a low protein, low sodium diet. This diet helps reduce the workload on the kidneys and manage edema, which are common issues in nephrotic syndrome. Choice A, high protein, low sodium, is not recommended because excessive protein intake can further strain the kidneys. Choice B, low protein, high sodium, is inappropriate as high sodium can worsen fluid retention and hypertension. Choice C, high protein, high potassium, is not ideal as high potassium levels can be problematic for individuals with kidney issues.

4. The health care provider is treating a child with meningitis with a course of antibiotic therapy. When should the nurse expect the child to be out of isolation?

• A. When the course of antibiotics is complete
• B. When a negative CNS culture is obtained
• C. When the antibiotics have been initiated for 24 hours
• D. When the child has no symptoms of the disease

Correct answer: C

Rationale: The correct answer is C because a child with bacterial meningitis should be isolated for at least 24 hours until antibiotic therapy has been initiated. This period allows the antibiotics to start working against the infection, reducing the risk of spreading it to others. Choice A is incorrect because isolation is not solely based on completing the course of antibiotics; the initiation is crucial. Choice B is incorrect as waiting for a negative CNS culture may take longer and delay necessary precautions. Choice D is incorrect as symptom resolution does not guarantee the eradication of the infection and may still pose a risk of transmission.

5. An older female client has normal saline infusing at 45 ml/hour. She complains of pain at the insertion of the IV catheter. There is no redness or edema around the IV site. Which action should the nurse take?

• A. Determine what IV medications have recently been administered.
• B. Slow the infusion rate.
• C. Apply a warm compress to the IV site.
• D. Discontinue the IV line and start a new one.

Correct answer: A

Rationale: The correct action for the nurse to take in this scenario is to determine what IV medications have recently been administered. This is important to identify if the pain at the IV site is related to a medication infusion. Slowing the infusion rate (choice B) may not address the underlying cause of the pain. Applying a warm compress (choice C) is not necessary since there is no redness or edema around the IV site. Discontinuing the IV line and starting a new one (choice D) is a drastic step and should not be the first action taken without investigating the cause of the pain.

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