Nursing Elites

1. In a mass casualty scenario at a child day care center, which child would the triage nurse prioritize for treatment last?

• A. An infant with intermittent bulging anterior fontanel between crying episodes
• B. A toddler with severe deep abrasions covering over 98% of the body
• C. A preschooler with 1 lower leg fracture and the other leg with an upper leg fracture
• D. A school-age child with singed eyebrows and hair on the arms

Correct answer: B

Rationale: In a mass casualty scenario, the triage nurse would prioritize the toddler with severe deep abrasions covering over 98% of the body for treatment last. This child is categorized as 'expectant' due to the extensive injuries, which are unlikely to be survivable even with immediate treatment. The other choices describe injuries that are serious but have a higher likelihood of survival with appropriate and timely intervention. The infant with an intermittent bulging anterior fontanel may have increased intracranial pressure requiring urgent evaluation, the preschooler with leg fractures can be stabilized and treated effectively, and the school-age child with singed hair likely has superficial burns which can be managed promptly.

2. A newly licensed nurse is preparing to administer medications to a client. The nurse notes that the provider has prescribed a medication that is unfamiliar. Which of the following actions should the nurse take?

• A. Consult the medication reference book available on the unit.
• B. Administer the medication as ordered.
• C. Ask a colleague for information about the medication.
• D. Contact the provider to clarify the medication.

Correct answer: A

Rationale: When encountering an unfamiliar medication, the safest action for a nurse is to consult the medication reference book available on the unit. This resource provides accurate and detailed information about medications, including indications, dosages, side effects, and nursing considerations. Administering a medication without understanding it (choice B) can lead to medication errors and harm to the client. Asking a colleague for information (choice C) may not always provide accurate or up-to-date information. Contacting the provider (choice D) should be reserved for situations where immediate clarification is needed, but consulting the reference book is the initial step to gain knowledge and ensure safe medication administration.

3. The healthcare provider is assessing a client with a history of congestive heart failure. Which assessment finding would be most concerning?

• A. Shortness of breath on exertion
• B. Weight gain of 2 pounds in a week
• C. Orthopnea
• D. Crackles in the lungs

Correct answer: D

Rationale: Crackles in the lungs are concerning because they indicate pulmonary congestion, a serious complication of congestive heart failure. The presence of crackles suggests fluid accumulation in the lungs, requiring immediate attention to prevent respiratory distress and worsening heart failure. While shortness of breath on exertion, weight gain, and orthopnea are common signs and symptoms of heart failure, crackles specifically point to acute pulmonary edema or worsening congestion, making them the most concerning finding in this scenario.

4. A client is receiving 0.9% sodium chloride IV at 125 mL/hr. The nurse notes that the client has received only 80 mL over the last 2 hr. Which of the following actions should the nurse take first?

• A. Reposition the client
• B. Document the client's IV intake in the medical record
• C. Request a new IV fluid prescription
• D. Check the IV tubing for obstruction

Correct answer: D

Rationale: The correct answer is to check the IV tubing for obstruction. The first step in the nursing process is assessment. By checking the IV tubing for obstruction, the nurse can assess and potentially correct any issues affecting the flow rate. This action may help to ensure that the prescribed infusion rate is maintained. Repositioning the client is not the priority at this stage as the issue seems related to the IV tubing. Documenting the intake or requesting a new prescription are not immediate actions needed to address the current situation with the IV fluid flow.

5. Which of the following findings contraindicate the use of haloperidol (Haldol) and warrant withholding the dose?

• A. Drowsiness, lethargy, and inactivity
• B. Dry mouth, nasal congestion, and blurred vision
• C. Rash, blood dyscrasias, severe depression
• D. Hyperglycemia, weight gain, and edema

Correct answer: C

Rationale: The correct answer is C: Rash, blood dyscrasias, and severe depression are serious side effects of haloperidol that necessitate withholding the dose and prompt further evaluation. Rash can indicate an allergic reaction, blood dyscrasias are serious blood disorders that can be life-threatening, and severe depression may worsen with haloperidol use. Choices A, B, and D are incorrect because drowsiness, lethargy, inactivity, dry mouth, nasal congestion, blurred vision, hyperglycemia, weight gain, and edema are common side effects of haloperidol that may not necessarily contraindicate its use but should be monitored and managed appropriately.

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