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. A client with type 2 diabetes mellitus arrives at the clinic reporting episodes of weakness and palpitations. Which finding should the nurse identify may indicate an emerging situation?

• A. History of hypertension
• B. Fingertips feel numb
• C. Reduced deep tendon reflexes
• D. Elevated fasting blood glucose level

Correct answer: B

Rationale: Numb fingertips may suggest neuropathy, a common complication of diabetes that may indicate a worsening condition. Episodes of weakness and palpitations, combined with neuropathy symptoms, could also suggest hypoglycemia or poor glycemic control, requiring further investigation. The other choices are less likely to be directly related to the client's current symptoms. While a history of hypertension is a common comorbidity in clients with diabetes, it may not directly explain the reported weakness and palpitations. Reduced deep tendon reflexes are more indicative of certain neurological conditions rather than acute emerging situations related to the client's current symptoms. An elevated fasting blood glucose level is expected in a client with type 2 diabetes and may not be the primary indicator of an emerging situation in this context.

3. While caring for a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values?

• A. White blood cell count
• B. Hemoglobin
• C. Serum creatinine
• D. Culture for sensitive organisms

Correct answer: D

Rationale: Purulent drainage suggests an infection at the wound site. Reviewing the culture and sensitivity results will guide appropriate antibiotic treatment by identifying the causative organisms and their antibiotic sensitivities. Elevated white blood cells indicate infection but do not specify the organism. Creatinine and hemoglobin values are unrelated to wound infections.

4. A client with a seizure disorder is prescribed phenytoin. What is the most important teaching the nurse should provide?

• A. Take phenytoin with antacids to reduce stomach upset.
• B. Maintain a consistent dosing schedule to prevent seizures.
• C. Monitor for excessive drowsiness and dizziness.
• D. Take the medication at bedtime to reduce seizure risk.

Correct answer: B

Rationale: The most important teaching the nurse should provide to a client prescribed phenytoin is to maintain a consistent dosing schedule to prevent seizures. Phenytoin is an antiepileptic drug, and missing doses can increase the risk of seizures. Option A is incorrect because antacids can interact with phenytoin and reduce its absorption. Option C is important but not the most critical teaching as compared to maintaining a consistent dosing schedule. Option D is incorrect because the timing of phenytoin administration should be consistent rather than specifically at bedtime.

5. The nurse assesses a client’s wound. What type of wound requires immediate intervention by the nurse?

• A. Laceration
• B. Abrasion
• C. Contusion
• D. Ulceration

Correct answer: A

Rationale: Lacerations, especially deep ones, are prone to bacterial contamination and may require immediate intervention to prevent infection. Abrasions, contusions, and ulcerations are not as likely to lead to immediate serious complications like infections as lacerations.

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