Nursing Elites

1. When educating a group of school-age children on reducing the risk of Lyme disease, which instruction should the camp nurse include?

• A. Wash hands frequently
• B. Avoid drinking lake water
• C. Wear long sleeves and pants
• D. Do not share personal products

Correct answer: C

Rationale: The correct instruction to reduce the risk of Lyme disease is to wear long sleeves and pants. This helps prevent tick bites, which are the primary mode of transmission for Lyme disease. Wearing protective clothing reduces the skin's exposure to ticks, decreasing the chances of getting bitten. Washing hands frequently (Choice A) is important for general hygiene but not specifically for preventing Lyme disease. Avoiding drinking lake water (Choice B) is unrelated to the prevention of Lyme disease. Not sharing personal products (Choice D) is important for preventing the spread of infections but does not directly reduce the risk of Lyme disease.

2. Several clients on a telemetry unit are scheduled for discharge in the morning, but a telemetry-monitored bed is needed immediately. The charge nurse should make arrangements to transfer which client to another medical unit? The client who is

• A. Learning to self-administer insulin injections after being diagnosed with diabetes mellitus
• B. Ambulatory following coronary artery bypass graft surgery performed six days ago.
• C. Wearing a sling immobilizer following permanent pacemaker insertion earlier that day
• D. Experiencing syncopal episodes resulting from dehydration caused by severe diarrhea

Correct answer: B

Rationale: The correct answer is B because the client who is ambulatory following coronary artery bypass graft surgery performed six days ago is stable enough for transfer compared to the other clients. Choice A should not be transferred as the client is still in the learning phase of self-administering insulin injections after being diagnosed with diabetes mellitus, requiring close monitoring. Choice C should not be transferred immediately after having a permanent pacemaker insertion as they need telemetry monitoring for any complications. Choice D should not be transferred as the client is experiencing syncopal episodes due to dehydration caused by severe diarrhea, requiring immediate intervention and close monitoring on the telemetry unit.

3. The nurse is preparing to administer an IM injection to a 6-month-old child. Which injection site is best for the nurse to use?

• A. Vastus lateralis
• B. Deltoid
• C. Ventrogluteal
• D. Dorsogluteal

Correct answer: A

Rationale: The vastus lateralis is the preferred site for IM injections in infants due to their limited muscle mass and safety. Infants do not have well-developed muscle mass, making the vastus lateralis the best option for IM injections. The deltoid muscle is typically used for older children and adults. Ventrogluteal and dorsogluteal sites are not recommended for infants due to safety concerns, including the risk of damaging the sciatic nerve. Therefore, the correct choice is the vastus lateralis for IM injections in infants.

4. A client with a history of dementia has become increasingly confused at night and is picking at an abdominal surgical dressing and the tape securing the intravenous (IV) line. The abdominal dressing is no longer occlusive, and the IV insertion site is pink. What intervention should the nurse implement?

• A. Replace the IV site with a smaller gauge.
• B. Redress the abdominal incision.
• C. Leave the lights on in the room at night.
• D. Apply soft bilateral wrist restraints.

Correct answer: C

Rationale: The correct intervention for a client with dementia who is becoming increasingly confused at night and interfering with dressings and IV lines is to leave the lights on in the room at night. This intervention can help reduce confusion and disorientation. Choice A is incorrect because changing the IV site gauge is not the priority in this situation. Choice B is not necessary unless there are signs of infection or other complications at the abdominal incision site, which are not mentioned in the scenario. Choice D should be avoided as using restraints should be a last resort and is not indicated in this case.

5. 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.

Similar Questions