Nursing Elites

1. A 15-year-old client has been placed in a Milwaukee Brace. Which statement from the adolescent indicates the need for additional teaching?

• A. I will only have to wear this for 6 months.
• B. I should inspect my skin daily.
• C. The brace will be worn day and night.
• D. I can take it off when I shower.

Correct answer: A

Rationale: The correct answer is A. The statement 'I will only have to wear this for 6 months' indicates a need for additional teaching because the Milwaukee Brace is typically worn for 12-18 months, not just 6 months. Choice B is correct as inspecting the skin daily is important to prevent skin breakdown. Choice C is correct as the brace is usually worn day and night for effectiveness. Choice D is correct as the brace can be removed when showering to maintain hygiene.

2. When reviewing car seat use with the parents of a 1-month-old infant, which of the following instructions should the nurse include?

• A. Use a car seat that has a three-point harness system.
• B. Position the car seat so that the infant is rear-facing.
• C. Secure the car seat in the front passenger seat of the vehicle.
• D. Convert to a booster seat after 12 months.

Correct answer: B

Rationale: The correct instruction for car seat use with a 1-month-old infant is to position the car seat so that the infant is rear-facing. This orientation provides the safest option for infants as it supports their head, neck, and spine. While using a car seat with a three-point harness system is appropriate for infants, placing the car seat in the front passenger seat is not recommended due to the presence of airbags, which can pose a risk to the infant in the event of deployment. Additionally, transitioning to a booster seat is not suitable at 12 months; infants should remain in rear-facing car seats until they outgrow the seat's height or weight limits, typically around 2 years of age.

3. When taking a history of a 3-year-old with neuroblastoma, what comment by the parents requires follow-up and is consistent with the diagnosis?

• A. The child has been listless and has lost weight.
• B. The urine is dark yellow and in small amounts.
• C. Clothes are becoming tighter across her abdomen.
• D. We notice muscle weakness and some unsteadiness.

Correct answer: C

Rationale: The correct answer is C. Clothes becoming tighter across the abdomen is indicative of an abdominal mass, a common presentation in neuroblastoma. This symptom should be followed up on further as it aligns with the diagnosis. Choices A, B, and D are less specific to neuroblastoma. Weight loss and listlessness (Choice A) can be nonspecific symptoms, while dark yellow urine in small amounts (Choice B) may suggest dehydration or other conditions. Muscle weakness and unsteadiness (Choice D) could point towards various neurological or muscular issues but are not as directly related to neuroblastoma as the symptom described in Choice C.

4. A client who is postoperative following abdominal surgery has an eviscerated wound. What should the nurse do first?

• A. Cover the incision with a moist sterile dressing.
• B. Notify the surgeon immediately.
• C. Assess the client's vital signs.
• D. Place the client in a supine position with knees bent.

Correct answer: A

Rationale: The initial action the nurse should take after discovering a client's eviscerated wound is to cover the incision with a moist sterile dressing. This step is crucial to protect the exposed tissue, prevent infection, and create a conducive environment for healing. While notifying the surgeon is important, addressing the wound immediately takes precedence. Assessing vital signs is essential but should follow the immediate intervention of covering the wound. Placing the client in a supine position with knees bent is not the priority in managing an eviscerated wound; the first step is to cover the wound to protect the exposed tissue.

5. When obtaining a urine specimen for a culture and sensitivity from an indwelling catheter, the nurse should:

• A. Cleanse the entry port prior to withdrawing urine.
• B. Use a sterile syringe to collect urine from the collection bag.
• C. Obtain the specimen from the drainage tubing.
• D. Replace the catheter before obtaining the specimen.

Correct answer: A

Rationale: The correct procedure when obtaining a urine specimen from an indwelling catheter for culture and sensitivity is to cleanse the entry port before withdrawing urine. This step helps reduce the risk of contamination and ensures the accuracy of the results. Option B is incorrect because using a sterile syringe to collect urine from the collection bag is not the recommended method for obtaining a catheter specimen. Option C is incorrect as obtaining the specimen from the drainage tubing is not the appropriate technique for collecting a urine sample from an indwelling catheter. Option D is incorrect because replacing the catheter before obtaining the specimen is not necessary and may introduce unnecessary complications.

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