Nursing Elites

1. The nurse is assessing a client 2 hours postoperatively after a femoral popliteal bypass. The upper leg dressing becomes saturated with blood. The nurse's first action should be to

• A. Wrap the leg with elastic bandages
• B. Apply pressure at the bleeding site
• C. Reinforce the dressing and elevate the leg
• D. Remove the dressings and re-dress the incision

Correct answer: B

Rationale: In this scenario where the upper leg dressing becomes saturated with blood post-femoral popliteal bypass, the nurse's first action should be to apply pressure at the bleeding site. Applying pressure is essential to control hemorrhage and prevent further blood loss. Choice A is incorrect as wrapping the leg with elastic bandages would not address the immediate issue of controlling the bleeding. Choice C is incorrect because reinforcing the dressing and elevating the leg should come after controlling the bleeding. Choice D is incorrect as removing the dressings and re-dressing the incision should only be done after the bleeding is under control to prevent excessive blood loss.

2. A parent asks the school nurse how to eliminate lice from their child. What is the most appropriate response by the nurse?

• A. Cut the child's hair short to remove the nits
• B. Apply warm soaks to the head twice daily
• C. Wash the child's linen and clothing in a bleach solution
• D. Application of pediculicides

Correct answer: D

Rationale: Pediculicides are the recommended treatment for lice and should be used to eliminate the infestation.

3. The nurse is caring for a client with a history of peptic ulcer disease. Which of these findings would be most concerning to the nurse?

• A. A heart rate of 72 beats per minute
• B. A hemoglobin level of 12 g/dL
• C. The client reports black, tarry stools
• D. The client reports nausea and vomiting

Correct answer: C

Rationale: Black, tarry stools can indicate gastrointestinal bleeding, which is a serious complication of peptic ulcer disease. This finding suggests active bleeding in the gastrointestinal tract, requiring immediate attention. A normal heart rate of 72 beats per minute (choice A) is within the expected range. A hemoglobin level of 12 g/dL (choice B) is also within normal limits. Nausea and vomiting (choice D) are common symptoms associated with peptic ulcer disease but may not necessarily indicate active bleeding like black, tarry stools.

4. A client is receiving intravenous antibiotics for the treatment of a severe infection. Which of these assessments is a priority for the nurse to perform?

• A. Monitor the client's temperature
• B. Assess the client's pain level
• C. Check the intravenous (IV) site for signs of phlebitis
• D. Monitor the client's respiratory status

Correct answer: C

Rationale: When a client is receiving intravenous antibiotics, checking the IV site for signs of phlebitis is a priority assessment for the nurse. Phlebitis is an inflammation of the vein, which can lead to serious complications such as infection and thrombosis. Monitoring the IV site helps prevent these complications and ensures the safe delivery of antibiotics. While monitoring the client's temperature, pain level, and respiratory status are important assessments, they are not the priority in this scenario where IV antibiotic administration requires close monitoring for complications like phlebitis.

5. What should a client with diarrhea avoid consuming?

• A. Orange juice
• B. Tuna
• C. Eggs
• D. Macaroni

Correct answer: A

Rationale: A client with diarrhea should avoid consuming orange juice. Orange juice is high in sugar content, which can worsen diarrhea symptoms by drawing water into the intestines, potentially leading to further dehydration and discomfort. Tuna, eggs, and macaroni are generally well-tolerated and do not exacerbate diarrhea symptoms, making them more suitable food choices for individuals experiencing diarrhea.

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