Nursing Elites

1. The school nurse is screening students for spinal abnormalities and instructs each student to stand up and then touch their toes. Which finding indicates that a student should be referred for scoliosis evaluation?

• A. Inability to touch their toes
• B. Asymmetry of the shoulders when standing upright
• C. Audible crepitus when bending
• D. An exaggerated upper thoracic convex curvature

Correct answer: B

Rationale: Asymmetry of the shoulders when standing upright is a common indicator of scoliosis. This finding suggests a possible spinal abnormality and should prompt further evaluation. Choices A, C, and D are not specific indicators of scoliosis. Inability to touch their toes may indicate flexibility issues or tightness in the hamstrings. Audible crepitus when bending may suggest joint degeneration or inflammation. An exaggerated upper thoracic convex curvature could indicate poor posture or other spinal abnormalities but is not directly indicative of scoliosis.

2. Which client requires careful nursing assessment for signs and symptoms of hypomagnesemia?

• A. A young adult client with intractable vomiting from food poisoning
• B. A client who developed hyperparathyroidism in late adolescence
• C. A middle-aged male client in renal failure following an unsuccessful kidney transplant
• D. A female client who is overzealous with her intake of simple carbohydrates

Correct answer: A

Rationale: The correct answer is A. Vomiting can lead to significant loss of magnesium, causing hypomagnesemia. In this scenario, the young adult client with intractable vomiting from food poisoning is at higher risk of developing hypomagnesemia due to the loss of magnesium through vomiting. Choices B, C, and D are less likely to present with hypomagnesemia. Hyperparathyroidism (B) is associated with hypercalcemia, renal failure (C) can lead to hypermagnesemia, and overconsumption of simple carbohydrates (D) is not directly linked to magnesium imbalances.

3. Which entry in the client record best reflects significant data on a male client who is admitted with complaints of chest pain?

• A. Nurse will check client q1h for the presence of chest pain
• B. Client has a nervous, tense personality and is likely to overreact
• C. Client states he will notify the nurse if chest pain returns
• D. Client understands how to use the call button and the telephone

Correct answer: C

Rationale: The correct answer is C because documenting the client's statement about notifying the nurse if chest pain returns provides direct, relevant information about their condition. This entry indicates the client's awareness of their symptoms and their willingness to seek assistance, which is crucial in managing chest pain. Choice A is incorrect because it focuses on the nurse's actions rather than the client's condition. Choice B is irrelevant as it discusses the client's personality rather than their current health issue. Choice D, though related to communication, does not directly address the client's chest pain complaint.

4. A client with a peripherally inserted central catheter (PICC) line has a fever. What client assessment is most important for the nurse to perform?

• A. Observe the PICC line site for inflammation.
• B. Encourage increasing fluid intake.
• C. Monitor blood pressure regularly.
• D. Assess skin turgor for dehydration.

Correct answer: A

Rationale: The correct answer is to observe the PICC line site for inflammation. When a client with a PICC line develops a fever, it could indicate an infection related to the catheter. Assessing the PICC line site for signs of inflammation, such as redness, warmth, swelling, or drainage, is crucial in identifying a potential infection early. Choice B is incorrect because increasing fluid intake is not directly related to assessing a PICC line for infection. Choice C is not the most appropriate assessment in this situation as monitoring blood pressure may not directly help in identifying the cause of the fever. Choice D is unrelated to the assessment of a fever in a client with a PICC line.

5. An adult male is admitted to the intensive care unit because he experienced a sudden onset of sharp chest pain and shortness of breath earlier today. Following an emergent pulmonary angiogram, the client is diagnosed with a pulmonary embolism. Which intervention is most important for the nurse to include in this client’s plan of care?

• A. Monitor signs of increased bleeding
• B. Instruct on the use of incentive spirometry
• C. Observe for confusion and restlessness
• D. Administer intravenous opioids for severe pain

Correct answer: A

Rationale: In a patient diagnosed with a pulmonary embolism, the most critical intervention is to monitor for signs of increased bleeding. Pulmonary embolism treatment often involves anticoagulation therapy, which increases the risk of bleeding. Monitoring for signs of bleeding such as bruising, petechiae, hematuria, or gastrointestinal bleeding is essential to prevent complications. Instructing on the use of incentive spirometry can be beneficial for preventing pulmonary complications but is not as urgent as monitoring for bleeding. Observing for confusion and restlessness may indicate hypoxia but is not the most crucial intervention in this scenario. Administering intravenous opioids for severe pain might be necessary but is not the priority compared to monitoring for bleeding, which is directly related to the treatment for pulmonary embolism.

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