Nursing Elites

1. What nursing assessment of a paralyzed client would indicate the probable presence of a fecal impaction?

• A. Presence of blood in stools
• B. Oozing liquid stool
• C. Continuous rumbling flatulence
• D. Absence of bowel movements

Correct answer: B

Rationale: The correct answer is B: 'Oozing liquid stool.' In a paralyzed client, oozing liquid stool is a common sign of fecal impaction. This occurrence requires prompt intervention to prevent complications. Choice A, 'Presence of blood in stools,' is more indicative of gastrointestinal bleeding rather than fecal impaction. Choice C, 'Continuous rumbling flatulence,' is associated with gas movement in the intestines and not specifically linked to fecal impaction. Choice D, 'Absence of bowel movements,' could be a sign of constipation but does not directly point towards fecal impaction.

2. A client is diagnosed with methicillin-resistant Staphylococcus aureus pneumonia. What type of isolation is most appropriate for this client?

• A. Reverse
• B. Airborne
• C. Standard precautions
• D. Contact

Correct answer: D

Rationale: The correct answer is 'D: Contact.' Contact precautions are necessary for clients with MRSA pneumonia to prevent the spread of the resistant bacteria. MRSA is primarily spread by direct contact, so using contact precautions, such as wearing gloves and gowns, is essential. Choice A, 'Reverse,' is not a type of isolation precaution. Choice B, 'Airborne,' is not the appropriate isolation for MRSA pneumonia, as MRSA is not transmitted through the airborne route. Choice C, 'Standard precautions,' are important for all clients, but for MRSA pneumonia specifically, contact precautions are more targeted and necessary.

3. When assessing a client for signs and symptoms of a fluid volume deficit, the nurse would be most concerned with which finding?

• A. Blood pressure of 90/60 mm Hg
• B. Heart rate of 110 beats per minute
• C. Respiratory rate of 24 breaths per minute
• D. Urine output of 30 mL per hour

Correct answer: A

Rationale: Corrected Rationale: A low blood pressure of 90/60 mm Hg is a significant finding indicating fluid volume deficit. In fluid volume deficit, the body tries to compensate by increasing heart rate (choice B) to maintain cardiac output. Respiratory rate (choice C) may increase as a compensatory mechanism, but it is not the primary concern in fluid volume deficit. Urine output (choice D) may decrease in response to fluid volume deficit, but it is a late sign and not the most concerning finding.

4. Which statement best describes the effects of immobility in children?

• A. Immobility prevents the progression of language and fine motor development
• B. Immobility in children has similar physical effects to those found in adults
• C. Children are more susceptible to the effects of immobility than adults are
• D. Children are likely to have prolonged immobility with subsequent complications

Correct answer: B

Rationale: The correct answer is B. Immobility in children indeed has physical effects similar to those found in adults. However, it can also significantly impact their development and growth. Choice A is incorrect because immobility does not solely prevent language and fine motor development but affects various aspects. Choice C is incorrect as susceptibility to the effects of immobility may vary between children and adults depending on individual factors. Choice D is incorrect as not all children are likely to have prolonged immobility with subsequent complications.

5. An antibiotic IM injection for a 2-year-old child is ordered. The total volume of the injection equals 2.0 ml. The correct action is to

• A. administer the medication in 2 separate injections
• B. give the medication in the ventrogluteal site
• C. call to get a smaller volume ordered
• D. check with the pharmacy for a liquid form of the medication

Correct answer: A

Rationale: Administering the medication in 2 separate injections is the correct action. When the total volume of an injection is relatively large for a specific site, dividing it into smaller volumes and administering them separately is a safer practice to prevent discomfort, tissue damage, or absorption issues. Giving the medication in the ventrogluteal site can be appropriate for IM injections but does not address the issue of the total volume being too high for a single injection. Calling to get a smaller volume ordered may delay treatment and is not necessary when a safe administration method is available. Checking with the pharmacy for a liquid form of the medication does not directly address the issue of the total volume being too high for a single injection, and changing the formulation may not be necessary if the correct administration technique can be applied.

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