Nursing Elites

1. The nurse admits a 7 year-old to the emergency room after a leg injury. The x-rays show a femur fracture near the epiphysis. The parents ask what will be the outcome of this injury. The appropriate response by the nurse should be which of these statements?

• A. The injury is expected to heal quickly because of thin periosteum.
• B. In some instances the result is a retarded bone growth.
• C. Bone growth is stimulated in the affected leg.
• D. This type of injury shows more rapid union than that of younger children.

Correct answer: B

Rationale: A fracture near the epiphysis can result in retarded bone growth, so this should be communicated to the parents.

2. During a blood transfusion, which observation indicates that the client is experiencing a transfusion reaction?

• A. The client reports feeling warm and flushed.
• B. The client develops a rash on the chest and back.
• C. The client experiences chills and a fever.
• D. The client complains of back pain and shortness of breath.

Correct answer: D

Rationale: Complaints of back pain and shortness of breath are classic signs of a transfusion reaction, specifically indicating a hemolytic reaction. This reaction can lead to the release of hemoglobin into the bloodstream, causing back pain and shortness of breath due to clot formation in the blood vessels, leading to decreased oxygen delivery. Warmth, flushing, rash, chills, and fever are more commonly associated with allergic reactions or febrile non-hemolytic reactions during transfusions. Therefore, options A, B, and C are incorrect in this context.

3. A healthcare professional is admitting a client who has decreased circulation in his left leg. Which of the following actions should the healthcare professional take first?

• A. Evaluate pedal pulses
• B. Assess skin temperature
• C. Check for capillary refill
• D. Measure the leg circumference

Correct answer: A

Rationale: Evaluating pedal pulses should be the first action taken as it provides immediate information about circulation. This assessment helps in determining the adequacy of blood flow in the client's leg. Assessing skin temperature, checking for capillary refill, and measuring leg circumference are important assessments; however, evaluating pedal pulses is the most crucial initial step in this scenario. Skin temperature assessment and capillary refill check can provide additional valuable information about perfusion, while measuring leg circumference is useful in monitoring for edema. Therefore, for a client with decreased circulation in the left leg, evaluating pedal pulses takes precedence over the other assessments.

4. A client has had their diet prescription changed to a mechanical soft diet. Which of the following food items should the nurse remove from the client's breakfast tray?

• A. smoothie
• B. sliced banana
• C. pancakes
• D. sunny side up (fried) eggs

Correct answer: D

Rationale: The correct answer is 'D: sunny side up (fried) eggs.' Fried eggs should be removed as they are not suitable for a mechanical soft diet due to their texture. The yolk of a fried egg is usually too hard and can be difficult for a client on a mechanical soft diet to chew and swallow. Poached or scrambled eggs are better alternatives for this diet as they are softer and easier to consume. Choices A, B, and C are all suitable for a mechanical soft diet as they are softer in texture and easier to chew and swallow.

5. A healthcare professional is preparing to administer 750 mL of 0.9% sodium chloride IV to infuse over 7 hours. The healthcare professional should set the pump to deliver how many mL/hr?

• A. 107 mL/hr
• B. 75 mL/hr
• C. 90 mL/hr
• D. 60 mL/hr

Correct answer: A

Rationale: To calculate the mL/hr rate for the infusion, divide the total volume (750 mL) by the total time (7 hours). 750 mL ÷ 7 hours = 107 mL/hr. This means that the pump should be set to deliver approximately 107 mL/hr. Choice B (75 mL/hr) is incorrect because it does not reflect the correct calculation. Choice C (90 mL/hr) is incorrect as it does not align with the accurate calculation. Choice D (60 mL/hr) is incorrect as it does not match the correct mL/hr rate obtained through the calculation.

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