Nursing Elites

1. Which type of Leukocyte is involved with allergic responses and the destruction of parasitic worms?

• A. Neutrophils
• B. Lymphocytes
• C. Eosinophils
• D. Monocytes

Correct answer: C

Rationale: Eosinophils are the correct answer. Eosinophils are specialized white blood cells that play a crucial role in allergic responses and combating parasitic infections. They release substances to destroy parasites and modulate allergic reactions. Neutrophils (Choice A) are mainly involved in fighting bacterial infections. Lymphocytes (Choice B) play a key role in the immune response, including antibody production, but are not primarily responsible for combating parasites or allergic responses. Monocytes (Choice D) are involved in immune defense, differentiating into macrophages or dendritic cells, but they are not mainly associated with allergic responses or parasitic worm destruction.

2. A client is admitted with acute low back pain. What action should the nurse implement to promote comfort?

• A. Ambulate with a walker for upper body support
• B. Perform abdominal curls to stretch the back muscles
• C. Position in semi-Fowler's with the knees flexed
• D. Encourage straight leg raises while lying supine

Correct answer: C

Rationale: Positioning the client in semi-Fowler's with the knees flexed is the most appropriate action to promote comfort in a client with acute low back pain. This position helps alleviate low back pain by reducing the pressure on the spine and supporting its natural curvature. Ambulating with a walker could strain the back, performing abdominal curls may exacerbate the pain, and straight leg raises while lying supine could cause further discomfort. Therefore, only positioning the client in semi-Fowler's with the knees flexed is the correct choice for promoting comfort in this scenario.

3. The nurse is completing a neurological assessment on a client with a closed head injury. The Glasgow Coma Scale (GCS) score was 13 on admission. It is now assessed at 6. What is the priority nursing intervention based on the client’s current GCS?

• A. Notify the healthcare provider of the GCS score
• B. Prepare the family for the client’s imminent death
• C. Monitor the client q1 hour for changes in the GCS score
• D. Begin cardiopulmonary resuscitation (CPR)

Correct answer: A

Rationale: A significant drop in GCS indicates a severe decline in neurological status, necessitating immediate communication with the healthcare provider. Notifying the healthcare provider allows for prompt evaluation and intervention to address the worsening condition. Choice B is incorrect because preparing the family for imminent death is premature and not supported by the information provided. Choice C is incorrect as the frequency of monitoring should be increased to every 15 minutes rather than every hour due to the significant drop in GCS. Choice D is incorrect because initiating CPR is not indicated based solely on a decreased GCS score.

4. The client is assessing a client who was recently diagnosed with heart failure and is on a low-sodium diet. Which statement by the client indicates a need for further teaching?

• A. “I will use lemon juice and herbs for flavoring.”
• B. “I will not eat canned soups or frozen dinners.”
• C. “I can have salt substitutes to enhance the taste of my food.”
• D. “I will check the food labels for sodium content before buying.”

Correct answer: C

Rationale: The correct answer is C. Some salt substitutes can be high in potassium, which may not be suitable for clients with heart failure. Option A is correct as using lemon juice and herbs for flavoring is a good low-sodium alternative. Option B is also correct as canned soups and frozen dinners are typically high in sodium content. Option D is correct as checking food labels for sodium content is an essential part of managing a low-sodium diet. Therefore, the client's statement about using salt substitutes needs correction as it can introduce high levels of potassium, which may not be recommended for individuals with heart failure.

5. After 2 days of treatment for dehydration, a child continues to vomit and have diarrhea. Normal saline is infusing, and the child’s urine output is 50ml/hour. During morning assessment, the nurse determines that the child is lethargic and difficult to arouse. Which action should the nurse implement?

• A. Perform a finger stick glucose test
• B. Increase the IV fluid flow rate
• C. Review 24-hour intake and output
• D. Obtain arterial blood gases

Correct answer: A

Rationale: Lethargy and difficulty arousing may indicate hypoglycemia, which should be assessed before other actions. Performing a finger stick glucose test is crucial to evaluate the child's blood sugar levels and address hypoglycemia promptly. Increasing the IV fluid flow rate is not indicated without knowing the glucose status. Reviewing 24-hour intake and output is important but not the priority when lethargy and difficulty arousing are present. Obtaining arterial blood gases is not the primary assessment needed in this situation.

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