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. The nurse assesses a client who has a nasal cannula delivering oxygen at 2 L/min. To assess for skin damage related to the cannula, which areas should the nurse observe?

• A. Tops of the ears
• B. Bridge of the nose
• C. Around the nostrils
• D. Over the cheeks

Correct answer: A

Rationale: When a client is using a nasal cannula for oxygen therapy, the areas prone to skin damage are the tops of the ears and around the nostrils. The pressure exerted by the cannula on these areas can lead to skin breakdown, so it is important for the nurse to observe these sites for any signs of damage. The correct answer is 'Tops of the ears.' Choices 'Bridge of the nose' and 'Over the cheeks' are not typically areas where skin damage related to the cannula would occur, making them incorrect choices.

3. A nurse is planning care for a client who has fluid overload. Which of the following actions should the nurse plan to take first?

• A. Evaluate electrolytes
• B. Restrict fluid intake
• C. Administer diuretics
• D. Monitor vital signs

Correct answer: A

Rationale: When a client has fluid overload, the nurse's first action should be to evaluate electrolytes. Electrolyte levels can be significantly affected by fluid imbalances, and assessing them will guide the nurse in determining the appropriate interventions. Restricting fluid intake (choice B) may be necessary but is not the initial priority. Administering diuretics (choice C) should be based on the electrolyte evaluation and overall assessment. Monitoring vital signs (choice D) is essential but does not provide direct information on the client's electrolyte status, which is crucial in managing fluid overload.

4. The nurse is caring for a client with a pressure ulcer on the sacrum. Which action should the LPN/LVN take to prevent further skin breakdown?

• A. Apply a hydrocolloid dressing to the ulcer.
• B. Reposition the client every 2 hours.
• C. Use a donut-shaped cushion when the client is sitting.
• D. Massage the area around the ulcer to promote circulation.

Correct answer: B

Rationale: Repositioning the client every 2 hours is the most appropriate action to prevent further skin breakdown in a client with a pressure ulcer on the sacrum. This practice helps relieve pressure on the affected area, promoting circulation and reducing the risk of tissue damage. Applying a hydrocolloid dressing (Choice A) may be beneficial for wound healing but is not the initial preventive measure. Using a donut-shaped cushion (Choice C) can actually increase pressure on the sacrum and worsen the condition. Massaging the area around the ulcer (Choice D) can further damage delicate skin and tissues, leading to more harm instead of prevention.

5. A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching?

• A. Use the complete name of the medication magnesium sulfate.
• B. Delete the space between the numerical dose and the unit of measure.
• C. Write the letter U when noting the dosage of insulin.
• D. Use the abbreviation SC when indicating an injection.

Correct answer: A

Rationale: The correct answer is to use the complete name of the medication magnesium sulfate. This is important to prevent confusion with morphine sulfate, which is abbreviated as MSO4. Choice B is incorrect as it is essential to maintain a space between the numerical dose and the unit of measure for clarity in medication documentation. Choice C is incorrect as the standard abbreviation for units is 'U' for international units, not for the dosage of insulin. Choice D is incorrect as the appropriate abbreviation for subcutaneous injection is 'SC,' not just 'SC.' Therefore, the nurse manager should emphasize using the full name of medications to avoid errors and ensure patient safety.

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