Nursing Elites

1. The nurse assigns a UAP to assist with the personal care of a client experiencing an acute exacerbation of multiple sclerosis. Which instruction should the nurse provide the UAP?

• A. Assist the client with a hot bath
• B. Encourage self-care but allow rest periods
• C. Face the client directly when speaking
• D. Keep the head of the bed elevated at all times

Correct answer: B

Rationale: The correct instruction for the UAP to provide when assisting a client experiencing an acute exacerbation of multiple sclerosis is to encourage self-care but allow rest periods. Clients with multiple sclerosis often experience fatigue, so promoting self-care activities while ensuring they have adequate rest periods is crucial for symptom management and maintaining independence. Choice A is incorrect as hot baths can potentially exacerbate symptoms in clients with multiple sclerosis. Choice C is unrelated to the client's care needs during an acute exacerbation of multiple sclerosis. Choice D is not a priority instruction in this situation and may not directly impact the client's immediate care needs.

2. While assessing an older male client who takes psychotropic medications, the nurse observes uncontrollable hand movements and excessive blinking. Which information in the client's medical record should the nurse review?

• A. Prescription for lorazepam
• B. History of Parkinson's disease
• C. Screening for tardive dyskinesia
• D. Recent urine drug screen report

Correct answer: C

Rationale: The symptoms of uncontrollable hand movements and excessive blinking are indicative of tardive dyskinesia, a possible side effect of long-term use of psychotropic medications. Reviewing the screening for tardive dyskinesia is crucial to assess if these symptoms are related to the medication. Option A, the prescription for lorazepam, is less relevant as the focus should be on potential side effects rather than the specific medication. Option B, history of Parkinson's disease, is not directly related to the observed symptoms, which are more likely linked to medication side effects. Option D, recent urine drug screen report, is not as pertinent in this context compared to reviewing the screening for tardive dyskinesia.

3. When administering parenteral iron, which action would be inconsistent with proper administration?

• A. Using the Z-track method
• B. Using an air bubble to avoid withdrawing medication into subcutaneous tissue
• C. Not massaging the injection site
• D. Using the deltoid muscle for administration

Correct answer: D

Rationale: The correct answer is D: Using the deltoid muscle for administration. Administering parenteral iron in the deltoid muscle is not recommended due to the risk of irritation and pain. The Z-track method (choice A) is preferred to prevent staining and irritation of the skin when administering irritating medications like iron. Using an air bubble (choice B) to avoid withdrawing medication into subcutaneous tissue is a common practice to ensure accurate administration. Not massaging the injection site (choice C) is also a standard practice to prevent potential irritation or bleeding at the injection site.

4. Patients are coming into the emergency room as a result of an apartment house fire. You are examining a patient who is in distress but has no visible burn marks. You suspect that she is suffering from inhalation burns. Which of the following signs would NOT be associated with inhalation burns?

• A. Singed nasal hairs
• B. Conjunctivitis
• C. Hoarseness
• D. Clear sputum

Correct answer: D

Rationale: Clear sputum would not be associated with inhalation burns. Inhalation burns typically present with symptoms like singed nasal hairs, conjunctivitis, hoarseness, and possibly soot in sputum due to smoke inhalation. Clear sputum suggests that there is no significant inflammation or injury to the respiratory tract, which is not consistent with the typical findings in inhalation burns. The other choices are associated with inhalation burns: singed nasal hairs can occur due to exposure to hot air or gases, conjunctivitis can result from irritating substances in smoke, and hoarseness can be due to airway irritation.

5. An 8-year-old is placed in 90-90 traction for a fractured femur resulting from a motor vehicle collision. Which finding requires further action by the nurse?

• A. No bowel movement for two days
• B. Mother assists child in changing positions
• C. Weights are touching the foot of the bed
• D. Child is able to move the toes freely when tickled

Correct answer: C

Rationale: The correct answer is C. In 90-90 traction, the weights should hang freely and not touch the foot of the bed to maintain proper traction and bone alignment. Option A is not necessarily a concern as bowel movements can be influenced by various factors, including diet changes and pain medication. Option B indicates good caregiver involvement, promoting comfort and preventing complications. Option D demonstrates neurovascular function, which is a positive finding. Therefore, the weights touching the foot of the bed is the finding that requires immediate attention to ensure the effectiveness of the traction.

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