Nursing Elites

1. A nurse is talking with caregivers of a 12-year-old child. Which of the following issues verbalized by the caregivers should the nurse identify as the priority?

• A. “We just don’t understand why our child can’t keep up with the other kids in simple activities like running and jumping.”
• B. “Our child keeps trying to find ways around our household rules. They always want to make deals with us.”
• C. “We think our child is trying too hard to excel in math just to get the top grades in the class.”
• D. “Our child likes to sing and worries it will make the other kids want to laugh.”

Correct answer: A

Rationale: The correct answer is A. Difficulty in keeping up with physical activities like running and jumping may indicate an underlying physical or developmental issue that requires prompt assessment. This could be related to musculoskeletal problems, coordination difficulties, or other health concerns that need further evaluation. Choices B, C, and D, while important, do not address a potential physical or developmental issue that could impact the child's overall well-being. Addressing the child's physical limitations should be the priority to ensure appropriate support and intervention.

2. A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular size cuff for a client who is obese. Which of the following explanations should the nurse give the AP?

• A. Using a cuff that is too small will result in an inaccurately high reading.
• B. Using a cuff that is too large will result in an inaccurately low reading.
• C. The regular size cuff is appropriate for all clients.
• D. You should use a cuff of any size as long as it fits.

Correct answer: A

Rationale: The correct answer is A: 'Using a cuff that is too small will result in an inaccurately high reading.' When obtaining blood pressure for an obese client, it is crucial to use a larger cuff to ensure an accurate reading. Choice B is incorrect because using a cuff that is too large for an obese client would actually result in an inaccurately low reading. Choice C is incorrect as a regular size cuff is not appropriate for obese clients due to their larger arm circumference. Choice D is incorrect because using a cuff of any size as long as it fits is not suitable for obtaining accurate blood pressure readings on an obese client.

3. A client receives the influenza vaccine in a clinic. Within 15 minutes after the immunization, the client complains of itchy and watery eyes, increased anxiety, and difficulty breathing. What should be the first action in the sequence of care for this client?

• A. Maintain the airway
• B. Administer epinephrine 1:1000 as ordered
• C. Monitor for hypotension with shock
• D. Administer diphenhydramine as ordered

Correct answer: B

Rationale: In the scenario described, the client is experiencing symptoms of an anaphylactic reaction, a severe allergic response. The priority action in an anaphylactic reaction is to administer epinephrine. Epinephrine helps counteract the severe allergic response, improves breathing difficulties, and maintains airway and circulation. Administering epinephrine takes precedence to stabilize the client's condition. Options A, C, and D may be necessary in the management of anaphylaxis, but the immediate priority is to administer epinephrine to address the life-threatening symptoms.

4. A client is postoperative following knee arthroplasty and requires the use of a thigh-length sequential compression device. Which of the following actions should the nurse take?

• A. Ensure two fingers can fit under the sleeves.
• B. Ensure the device is not too tight to impede circulation.
• C. Position the client comfortably before applying the device.
• D. Use the device continuously to prevent blood clots.

Correct answer: A

Rationale: The correct action for the nurse to take when applying a thigh-length sequential compression device to a postoperative client is to ensure that two fingers can fit under the sleeves. This action helps prevent the device from being too tight, which could impede circulation. Choice B is incorrect because the device should not be too tight, as it could lead to circulation issues. Choice C is incorrect as the client should be in a comfortable position, not necessarily supine. Choice D is incorrect as sequential compression devices are typically used continuously to prevent blood clots.

5. An elderly male client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral feedings through a gastrostomy tube. What is the best client position for the administration of bolus tube feedings?

• A. Prone.
• B. Fowler's.
• C. Sims'.
• D. Supine.

Correct answer: B

Rationale: The correct answer is Fowler's position. Placing the client in Fowler's position, with the head of the bed elevated to 45-60 degrees, reduces the risk of aspiration during bolus enteral feedings by facilitating the flow of the feeding into the stomach. Prone position (choice A) is lying face down, which is not suitable for feeding. Sims' position (choice C) is a side-lying position used for rectal examinations or enemas, not for feeding. Supine position (choice D) is lying flat on the back and is not optimal for reducing the risk of aspiration during bolus tube feedings.

Similar Questions