Nursing Elites

1. A school nurse is called to the soccer field because a child has a nosebleed (epistaxis). In what position should the nurse place the child?

• A. Sitting up and leaning forward
• B. Reclining with head elevated
• C. Sitting up with head tilted back
• D. Lying flat on the back

Correct answer: A

Rationale: The correct position for a child with a nosebleed (epistaxis) is sitting up and leaning forward. This position helps prevent blood from flowing into the throat and causing choking. Choice B, reclining with the head elevated, and choice D, lying flat on the back, are incorrect as they can cause blood to flow backward into the throat. Choice C, sitting up with the head tilted back, is also incorrect as it can lead to blood flowing down the back of the throat and potentially into the airway.

2. Two days after an abdominal hysterectomy, an elderly female with diabetes has a syncopal episode. The nurse determines that her vital signs are within normal limits, but her blood sugar is 325 mg/dL or 18.04 mmol/L (SI). What intervention should the nurse implement first?

• A. Administer regular insulin per sliding scale
• B. Cancel the client's dinner tray
• C. Give the client 4 ounces (120 mL) of orange juice
• D. Administer the next scheduled dose of metformin

Correct answer: A

Rationale: In this case, the nurse should implement the intervention of administering regular insulin per sliding scale. High blood sugar levels, as indicated by a reading of 325 mg/dL, require insulin administration to prevent complications such as hyperglycemia. Canceling the client's dinner tray (choice B) would not address the immediate need to lower the blood sugar level. Giving the client orange juice (choice C) might further increase the blood sugar level as it contains sugar. Administering the next scheduled dose of metformin (choice D) is not appropriate as metformin is not typically used for acute management of high blood sugar levels.

3. The unlicensed assistive personnel (UAP) has applied a gown and gloves and secured the tops of the gloves over the gown sleeves. What action should the nurse take?

• A. Confirm that the gown is tied securely at the neck and waist
• B. Remind the UAP to wash hands frequently while in the room
• C. Assist the UAP with application of the face mask or face shield
• D. Help the UAP reposition the gown sleeve over the gloves edges

Correct answer: D

Rationale: Proper application of personal protective equipment (PPE) is crucial to maintain infection control. In this scenario, the nurse should help the UAP reposition the gown sleeve over the gloves' edges. This action ensures that the gown properly covers the gloves, reducing the risk of contamination. Choices A, B, and C are incorrect because the primary concern is to address the improper application of PPE by repositioning the gown sleeves over the gloves, not checking other aspects of PPE or reminding about hand hygiene.

4. A 2-year-old boy with short bowel syndrome has progressed to receiving enteral feedings only. Today his stools are occurring more frequently and have a more liquid consistency. His temperature is 102.2 °F, and he has vomited twice in the past four hours. Which assessment finding indicates that the child is becoming dehydrated?

• A. Occult blood in the stool
• B. Abdominal distention
• C. Elevated urine specific gravity
• D. Hyperactive bowel sounds

Correct answer: C

Rationale: Elevated urine specific gravity indicates concentrated urine, a sign of dehydration. In this scenario, the child is showing signs of dehydration with increased stool frequency, liquid consistency, fever, and vomiting. Occult blood in the stool may indicate gastrointestinal bleeding but is not a specific sign of dehydration. Abdominal distention can be seen in various conditions and is not a specific indicator of dehydration. Hyperactive bowel sounds can be present in various gastrointestinal conditions but are not directly related to dehydration.

5. When should the nurse conduct an Allen’s test?

• A. When obtaining pulmonary artery pressures
• B. To assess for the presence of a deep vein thrombus in the leg
• C. Just before arterial blood gases are drawn peripherally
• D. Prior to attempting a cardiac output calculation

Correct answer: C

Rationale: The correct time to conduct an Allen’s test is just before arterial blood gases are drawn peripherally. This test is performed to assess the adequacy of collateral circulation in the hand before obtaining arterial blood gases. Choice A is incorrect because an Allen’s test is not specifically done when obtaining pulmonary artery pressures. Choice B is incorrect because an Allen’s test is not used to assess deep vein thrombosis. Choice D is incorrect because an Allen’s test is not done specifically before attempting a cardiac output calculation.

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