Nursing Elites

1. A 16-year-old adolescent with cystic fibrosis is admitted to the hospital with a respiratory infection. The nurse is teaching the adolescent about the importance of airway clearance techniques. Which statement by the adolescent indicates a need for further teaching?

• A. I should do my airway clearance exercises every day.
• B. I don’t need to do my airway clearance exercises if I feel okay.
• C. Airway clearance helps prevent mucus buildup in my lungs.
• D. I should continue my airway clearance routine even when I’m not sick.

Correct answer: B

Rationale: The correct answer is B. Airway clearance exercises are essential for individuals with cystic fibrosis to prevent mucus buildup in their lungs. It is crucial to perform these exercises regularly, even when feeling well, to maintain lung health and prevent complications. Choice A is correct as doing airway clearance exercises daily is necessary. Choice C is also accurate as airway clearance does indeed help prevent mucus buildup. Choice D is correct as it is important to continue the airway clearance routine even when not sick to maintain lung health. Choice B is incorrect because stating that airway clearance exercises are unnecessary when feeling okay demonstrates a misunderstanding of the importance of consistent airway clearance in cystic fibrosis management.

2. The parents of a 10-year-old child with newly diagnosed type 1 diabetes are being taught by the nurse about managing their child’s condition. Which statement by the parents indicates they need further teaching?

• A. We should rotate injection sites to prevent tissue damage
• B. Our child should avoid all sugary foods and drinks
• C. We will monitor blood glucose levels regularly
• D. Our child needs to wear a medical alert bracelet

Correct answer: B

Rationale: It is important for individuals with diabetes to manage their carbohydrate intake, including sugary foods and drinks, rather than completely avoiding them. Sugary foods should be consumed in moderation as part of a balanced diet to help maintain stable blood glucose levels.

3. A 2-week-old female infant is hospitalized for the surgical repair of an umbilical hernia. After returning to the postoperative neonatal unit, her RR and HR have increased during the last hour. Which intervention should the nurse implement?

• A. Notify the healthcare provider of these findings
• B. Administer a PRN analgesic as prescribed
• C. Document the findings in the infant's medical record
• D. Comfort the infant by swaddling and gently rocking

Correct answer: A

Rationale: In a postoperative neonatal setting, an increase in respiratory rate (RR) and heart rate (HR) in an infant could indicate pain or distress. It is crucial for the nurse to notify the healthcare provider promptly to assess the infant's condition and provide appropriate interventions. Prompt communication with the healthcare provider ensures timely evaluation and management of the infant's discomfort or distress, promoting optimal postoperative recovery and comfort. Administering analgesics without healthcare provider assessment could mask underlying issues, documenting findings alone does not address the immediate need for intervention, and comforting may not resolve the underlying cause of increased RR and HR.

4. A 16-year-old male client who has been treated in the past for a seizure disorder is admitted to the hospital. Immediately after admission, he begins to have a grand mal seizure. Which action should the nurse take?

• A. Obtain assistance in holding him to prevent injury.
• B. Observe him carefully.
• C. Call a CODE.
• D. Place a padded tongue blade between the teeth.

Correct answer: B

Rationale: During a grand mal seizure, the priority action for the nurse is to ensure the safety of the client. Observing the client carefully allows the nurse to monitor the seizure activity, the client's breathing, and any signs of distress without interfering with the seizure process. Restraining the client or placing objects in the mouth can lead to injury and should be avoided. Calling a CODE is not appropriate for a seizure as it is a normal response to the client's condition.

5. A 3-year-old child with a high fever and sore throat is brought to the clinic. The nurse observes that the child is drooling and has difficulty swallowing. What is the nurse’s priority action?

• A. Administer antipyretic medication
• B. Prepare for emergency airway management
• C. Offer the child ice chips to suck on
• D. Assess the child’s hydration status

Correct answer: B

Rationale: In a 3-year-old child with drooling, difficulty swallowing, high fever, and sore throat, the nurse should prioritize preparing for emergency airway management. These signs may indicate epiglottitis, a condition that can quickly obstruct the airway, leading to respiratory distress and potentially fatal outcomes if not managed promptly. Administering antipyretic medication (Choice A) may be necessary later but is not the priority. Offering ice chips (Choice C) is contraindicated as the child has difficulty swallowing. Assessing hydration status (Choice D) is important but not the priority when the airway is at risk.

Similar Questions