Nursing Elites

1. Which factors will the nurse consider when calculating the CURB-65 score for a patient with pneumonia? (Select one that does not apply)

• A. Age
• B. Blood pressure
• C. Respiratory rate
• D. Oxygen saturation

Correct answer: D

Rationale: The correct answer is 'Oxygen saturation.' When calculating the CURB-65 score for a patient with pneumonia, the factors considered include mental status (confusion), BUN (elevated), blood pressure (decreased), respiratory rate (increased), and age (65 and older). Oxygen saturation is not used in the CURB-65 scoring system. While blood pressure, respiratory rate, and age are factors that are used in the calculation of the CURB-65 score, oxygen saturation is not part of the scoring criteria. Therefore, oxygen saturation is the factor that does not apply when calculating the CURB-65 score.

2. A mother brings her 5-week-old infant to the health care clinic and tells the nurse that the child has been vomiting after meals. The mother reports that the vomiting is becoming more frequent and forceful. The nurse suspects pyloric stenosis and asks the mother which assessment question to elicit data specific to this condition?

• A. Are the stools ribbon-like, and is the infant eating poorly?
• B. Does the infant suddenly become pale, begin to cry, and draw the legs up to the chest?
• C. Does the vomit contain sour, undigested food without bile, and is the infant constipated?
• D. Does the infant cry loudly and continuously during the evening hours but nurses or takes formula well?

Correct answer: C

Rationale: Vomiting undigested food that is not bile stained and constipation are classic symptoms of pyloric stenosis. Stools that are ribbon-like and a child who is eating poorly are signs of congenital megacolon (Hirschsprung's disease). An infant who suddenly becomes pale, cries out, and draws the legs up to the chest is demonstrating physical signs of intussusception. Crying during the evening hours, appearing to be in pain, eating well, and gaining weight are clinical manifestations of colic.

3. A woman in her third trimester complains of severe heartburn. What is appropriate teaching by the nurse to help the woman alleviate these symptoms?

• A. Drink small amounts of liquids frequently
• B. Eat the evening meal at least 2-3 hours before bedtime
• C. Take sodium bicarbonate after each meal
• D. Sleep with head propped on several pillows

Correct answer: D

Rationale: During the third trimester, many women experience heartburn due to the pressure of the growing uterus on the stomach. Elevating the head while sleeping can help prevent gastric contents from refluxing back into the esophagus, thus reducing heartburn symptoms. Drinking small amounts of liquids frequently may exacerbate heartburn by increasing stomach distension. Eating the evening meal just before retiring can also worsen heartburn symptoms as lying down shortly after eating can promote reflux. Taking sodium bicarbonate after each meal is not recommended as it can disrupt the body's natural pH balance and lead to other complications.

4. Which of the following clients is most appropriate for receiving telemetry?

• A. A client with syncope potentially related to cardiac dysrhythmia
• B. A client with unstable angina
• C. A client with sinus rhythm and PVCs
• D. A client who had a myocardial infarction 6 hours ago

Correct answer: A

Rationale: Telemetry is used to monitor the cardiac rhythms of clients with potentially unstable conditions or those rhythms that affect activities. Clients with syncope potentially related to cardiac dysrhythmia require continuous monitoring to detect any potential life-threatening dysrhythmias. Unstable angina can be monitored in a telemetry unit, but syncope with potential cardiac causes takes precedence. Clients with sinus rhythm and PVCs may not necessitate telemetry unless there are further indications of instability. A client who had a myocardial infarction 6 hours ago is typically monitored in an intensive care unit rather than a telemetry unit.

5. A 4-year-old hospitalized child begins to have a seizure while playing with hard plastic toys in the hallway. Of the following nursing actions, which one should the nurse do first?

• A. Place the child in the nearest bed
• B. Administer IV medication to slow down the seizure
• C. Place a padded tongue blade in the child's mouth
• D. Remove the child's toys from the immediate area

Correct answer: D

Rationale: During a seizure, the priority nursing actions are to ensure the safety of the child and maintain airway patency. Placing objects in the child's mouth, like a padded tongue blade, is not recommended as it can lead to injury or obstruction of the airway. Moving the child to a bed is also not the immediate priority during a seizure. Administering IV medication to slow down the seizure is not typically done as the initial action. Therefore, the correct first nursing action is to remove any potential hazards, such as the hard plastic toys, from the immediate area to prevent injury during the seizure.

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