Nursing Elites

1. What is the first action the nurse should take when treating a 6-year-old child who stepped on a rusty nail?

• A. Cleanse the foot with soap and water
• B. Instruct the parent about tetanus boosters
• C. Apply a sterile dressing and refer for a tetanus booster
• D. Elevate the foot and wrap in a compression bandage

Correct answer: B

Rationale: The correct first action when a 6-year-old child steps on a rusty nail is to instruct the parent about tetanus boosters. This is important because stepping on a rusty nail increases the risk of tetanus infection. Choice A is incorrect as cleansing the foot comes after addressing the tetanus risk. Choice C is not the first action and should be done after addressing the immediate risk of tetanus. Choice D is not necessary as the priority is to prevent tetanus infection.

2. During an excretory urogram, which observation made by the nurse indicates a complication?

• A. The client complains of a salty taste in the mouth when the dye is injected
• B. The client's entire body turns a bright red color
• C. The client states 'I have a feeling of getting warm.'
• D. The client gags and complains 'I am getting sick.'

Correct answer: B

Rationale: The correct answer is B because a whole-body bright red color indicates a severe reaction to the contrast dye and must be addressed immediately. Choices A, C, and D do not indicate a severe complication during an excretory urogram. Choice A is a common side effect of the dye, choice C could be a normal sensation due to the injection, and choice D may indicate nausea which is less severe compared to a whole-body red color reaction.

3. A client with a prescription for DNR begins to manifest signs of impending death. After notifying the family of the client's status, what priority action should the nurse implement?

• A. Inform the healthcare provider
• B. Determine the client's need for pain medication
• C. Begin comfort measures
• D. Ensure all life-saving equipment is removed

Correct answer: B

Rationale: The correct priority action for the nurse to implement in this scenario is to determine the client's need for pain medication. Ensuring that the client is comfortable and free from pain is crucial in end-of-life care, especially for a client with a Do Not Resuscitate (DNR) order. This action prioritizes the client's comfort and dignity in their final moments. While informing the healthcare provider and beginning comfort measures are important aspects of care, pain management takes precedence as the immediate priority. Removing life-saving equipment is not appropriate at this stage as it goes against the client's wishes stated in the DNR order.

4. A preschool-aged boy is admitted to the pediatric unit following successful resuscitation from a near-drowning incident. While providing care to the child, the nurse begins talking with his preadolescent brother who rescued the child from the swimming pool and initiated resuscitation. The nurse notices the older boy becomes withdrawn when asked about what happened. Which action should the nurse take?

• A. Involve the older brother in supporting the child
• B. Ask the older brother how he felt during the incident
• C. Ask the parents for more information about the brother's behavior
• D. Reassure the brother that everything is fine now

Correct answer: B

Rationale: The older brother's withdrawal likely indicates emotional trauma or stress from the near-drowning event. Asking how he felt provides an opportunity for emotional support and allows the child to express feelings that may need addressing. Involving him in supporting the child may be overwhelming and not address his emotional needs directly. Asking the parents for more information may not allow the older brother to express his own feelings. Simply reassuring him that everything is fine now may dismiss his emotional experience without providing a chance for him to process his feelings.

5. What instruction should the nurse include for a client prescribed nitroglycerin for a myocardial infarction?

• A. Take the medication only when experiencing severe chest pain.
• B. Store the medication in a dark container to protect it from light.
• C. Take the medication before engaging in physical activity that may trigger chest pain.
• D. Limit nitroglycerin use to no more than three doses in 15 minutes.

Correct answer: D

Rationale: The correct answer is D: 'Limit nitroglycerin use to no more than three doses in 15 minutes.' This instruction is crucial to prevent excessive use, which can lead to severe hypotension and other complications. Choice A is incorrect because nitroglycerin should also be used preventatively, not only during severe chest pain. Choice B is irrelevant and not a necessary instruction for nitroglycerin use. Choice C is incorrect as nitroglycerin is typically taken to prevent chest pain rather than waiting for an activity that may trigger it.

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