Nursing Elites

1. Which techniques should be used to administer an intradermal (ID) injection for a Mantoux test to screen for tuberculosis (TB)? Select all that apply.

• A. Observe for an intradermal bleed after the antigen is injected
• B. Select an ID site using the volar surface of the forearm
• C. Use a 26 or 27-gauge needle with a length of 1/4 to 5/8 inches on a 1 ml calibrated syringe
• D. Ensure that the needle is inserted into the skin with the bevel up

Correct answer: A

Rationale: Observing for an intradermal bleed after the antigen is injected is a proper technique for an ID injection. This is important to confirm the correct placement of the injection. Choice B is correct because the recommended site for an ID injection for a Mantoux test is the volar surface of the forearm. Choice C is incorrect because the standard needle size for an ID injection is usually 26 or 27 gauge with a length of 1/4 to 5/8 inches, not 25 gauge with a length of 1/2 inch. Choice D is incorrect because the needle should be inserted into the skin with the bevel facing up, not down.

2. The healthcare provider prescribed furosemide for a 4-year-old child with a ventricular septal defect. Which outcome indicates to the nurse that this pharmacological intervention was effective?

• A. Urine specific gravity changing from 1.021 to 1.031
• B. Daily weight decrease of 2 pounds (0.9 kg)
• C. Blood urea nitrogen (BUN) increasing from 8 to 12 mg/dl (2.9 to 4.3)
• D. Urinary output decreasing by 5 ml/hour

Correct answer: B

Rationale: The correct answer is B. A daily weight decrease of 2 pounds (0.9 kg) is the most appropriate outcome to indicate the effectiveness of furosemide in a child with a ventricular septal defect. Furosemide is a diuretic medication that helps reduce fluid retention. Therefore, a decrease in weight reflects a reduction in fluid volume, which is the desired effect of furosemide. Choices A, C, and D are incorrect because changes in urine specific gravity, blood urea nitrogen (BUN) levels, and urinary output do not directly reflect the effectiveness of furosemide in this context.

3. When caring for a client with Cushing syndrome, which serum laboratory value is most important for the nurse to monitor?

• A. Lactate
• B. Glucose
• C. Hemoglobin
• D. Creatinine

Correct answer: B

Rationale: When caring for a client with Cushing syndrome, monitoring glucose levels is crucial as Cushing syndrome often leads to hyperglycemia. Elevated glucose levels are a common manifestation of Cushing syndrome due to increased cortisol levels. Monitoring glucose helps in assessing and managing the client's condition effectively. Lactate levels are not typically affected by Cushing syndrome. Hemoglobin and creatinine levels are important for other conditions like anemia and kidney function, but they are not the priority in Cushing syndrome.

4. The nurse is planning care for a family whose children did not receive childhood immunizations. After one of the children contracted mumps, the father is diagnosed with orchitis. Which intervention should be included in the father's plan of care?

• A. Use of bedrest with scrotal support
• B. Administration of antibiotics for 10 days
• C. Applying heat to promote the healing process
• D. Using an ice pack to reduce scrotal pain

Correct answer: A

Rationale: For orchitis, the recommended intervention is bedrest with scrotal support. This helps reduce swelling and discomfort in the scrotum. Antibiotics are generally not required for viral orchitis, so administering antibiotics for 10 days (Choice B) is not indicated. Applying heat (Choice C) may worsen swelling and should be avoided. Using an ice pack (Choice D) is not the preferred method for managing orchitis; it may not be as effective as providing support and rest for the scrotum.

5. The nurse enters the room of a client who is awaiting surgery for appendicitis. The unlicensed assistive personnel (UAP) has helped the client to a position of comfort with the right leg flexed and has applied a heating pad to the client’s abdomen to relieve the client’s pain. Which action should the nurse implement first?

• A. Remove the heating pad.
• B. Reposition the client’s right leg.
• C. Monitor for signs of inflammation.
• D. Assess the client’s pain level.

Correct answer: A

Rationale: The correct action for the nurse to implement first is to remove the heating pad. Heating pads should not be used for suspected appendicitis as they can mask symptoms and potentially worsen inflammation. Choice B is not the priority as the position of comfort chosen by the UAP may be appropriate. Monitoring for signs of inflammation (Choice C) is important but not the initial action to address the immediate issue of the heating pad. Assessing the client's pain level (Choice D) can be done after removing the heating pad to evaluate the effectiveness of pain relief measures.

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