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. A client with renal disease seems anxious and presents with the onset of shortness of breath, lethargy, edema, and weight gain. Which action should the nurse implement first?

• A. Determine serum potassium level
• B. Calculate the client’s daily fluid intake
• C. Assess client for signs of vertigo
• D. Review the client’s pulse oximetry reading

Correct answer: A

Rationale: The correct answer is to determine the client's serum potassium level. In a client with renal disease experiencing symptoms like shortness of breath, lethargy, edema, and weight gain, assessing serum potassium levels is crucial. Electrolyte imbalances, including potassium, can lead to serious complications such as cardiac arrhythmias and muscle weakness. Calculating daily fluid intake may be important but addressing acute symptoms related to electrolyte imbalances takes precedence. Assessing for signs of vertigo and reviewing pulse oximetry reading are not the priority in this scenario compared to assessing and managing potential electrolyte imbalances.

3. The client had gastric bypass surgery yesterday. Which intervention is most important for the nurse to implement during the first 24 postoperative hours?

• A. Insert an indwelling urinary catheter
• B. Monitor for the appearance of an incisional hernia
• C. Instruct the client to eat small frequent meals
• D. Measure hourly urinary output

Correct answer: D

Rationale: Monitoring hourly urinary output is crucial during the first 24 postoperative hours to assess kidney function, fluid balance, and early detection of complications like dehydration or inadequate kidney perfusion. Inserting an indwelling urinary catheter is not routinely necessary after gastric bypass surgery unless there are specific indications. Monitoring for an incisional hernia is important but not the highest priority in the immediate postoperative period. Instructing the client to eat small frequent meals is essential for long-term dietary management after gastric bypass surgery, but not the most critical intervention during the initial 24 hours.

4. The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (PN), and an unlicensed assistive personnel (UAP). Which task should the charge nurse assign to the RN?

• A. Transport a client who is receiving IV fluid to the radiology department
• B. Administer PRN oral analgesics to a client with a history of chronic pain
• C. Supervise a newly hired graduate nurse during an admission assessment
• D. Complete ongoing focused assessments of a client with wrist restraints

Correct answer: C

Rationale: The correct answer is C because supervising a newly hired graduate nurse during an admission assessment is a task that falls within the registered nurse's scope of practice. Registered nurses are responsible for overseeing and delegating tasks, especially to new staff, to ensure proper assessment and care delivery. Choices A, B, and D involve tasks that can be appropriately assigned to practical nurses or unlicensed assistive personnel as they are within their scope of practice. Transporting a client, administering oral analgesics, and completing focused assessments do not require the advanced knowledge and skills of a registered nurse.

5. The nurse is assessing a first-day postpartum client. Which finding is most indicative of a postpartum infection?

• A. Oral temperature of 100.2°F (37.9°C)
• B. Blood pressure of 122/74 mmHg
• C. Moderate amount of foul-smelling lochia
• D. White blood count of 19,000/mm³ (19x10^9/L SI units)

Correct answer: C

Rationale: A foul-smelling lochia is indicative of a postpartum infection, such as endometritis. Foul-smelling lochia suggests the presence of infection due to the breakdown of tissue by bacteria, leading to the malodor. An oral temperature elevation and an elevated white blood cell count are nonspecific and can be present in various conditions other than postpartum infections, making them less indicative. A blood pressure within normal limits is not typically associated with postpartum infections.

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