Nursing Elites

1. A 2-year-old child with laryngotracheobronchitis (LTB) is fussy and restless in the oxygen tent. The oxygen level in the tent is 25%, and blood gases are normal. What would be the correct action by the nurse?

• A. Restrain the child in the tent and notify the health care provider.
• B. Increase the oxygen concentration in the tent.
• C. Take the child out of the tent and into the playroom.
• D. Ask the mother for help in comforting the child.

Correct answer: B

Rationale: The child with LTB should be placed in the mist tent with 30% oxygen. Restlessness is caused by poor oxygenation. The child should not be taken out of the oxygenated tent. While the mother could be asked to help comfort the child, and the health care provider may be notified, the priority is to set the oxygen at the correct level.

2. While performing a skin assessment on an older adult, the nurse notices a number of irregular round brownish-colored lesions on the client’s hands, arms, and face. On palpation, they are flat and slightly rough to the touch. Based on this assessment finding, which action should the nurse implement?

• A. Apply a topical antibiotic ointment.
• B. Monitor the lesions for changes.
• C. Advise the client to use sunscreen.
• D. Refer the client for a skin lesion biopsy.

Correct answer: D

Rationale: Referral for a skin biopsy is necessary to rule out potential malignancy of irregular skin lesions. Applying a topical antibiotic ointment (Choice A) is not indicated for irregular pigmented lesions. Monitoring the lesions for changes (Choice B) may delay appropriate intervention if malignancy is present. Advising the client to use sunscreen (Choice C) is important for sun protection but is not the priority when irregular lesions are present.

3. An adolescent female asks the nurse about taking retinoic acid (Accutane). What guidance should be provided by the nurse?

• A. The medication should be used for 10 weeks only.
• B. The medication requires that sexually active females use contraception.
• C. The medication lowers hemoglobin levels very quickly.
• D. The medication has few side effects.

Correct answer: B

Rationale: The correct guidance the nurse should provide is that sexually active females must use contraception while taking Accutane and for 1 month after the 20 weeks it is prescribed. Choice A is incorrect because Accutane is typically taken for a longer duration than 10 weeks. Choice C is incorrect because Accutane does not lower hemoglobin levels quickly. Choice D is incorrect as Accutane is known for having many side effects, including the risk of birth defects.

4. The nurse is providing postoperative care for a client who had a thyroidectomy. Which assessment finding requires immediate intervention?

• A. Hoarseness and weak voice
• B. Calcium level of 8.0 mg/dL (2.0 mmol/L)
• C. Heart rate of 110 beats per minute
• D. Difficulty swallowing

Correct answer: D

Rationale: Difficulty swallowing can indicate swelling or hematoma formation, which may compromise the airway and requires immediate intervention. Hoarseness and a weak voice are expected post-thyroidectomy due to manipulation of the laryngeal nerves but do not require immediate intervention. A calcium level of 8.0 mg/dL is within the normal range (8.5-10.5 mg/dL) and may not require immediate intervention. A heart rate of 110 beats per minute may be elevated due to stress or pain postoperatively, but it does not indicate an immediate threat to the airway.

5. During a paracentesis, two liters of fluid are removed from the abdomen of a client with ascites. A drainage bag is placed, and 50 ml of straw-colored fluid drains within the first hour. What action should the nurse implement?

• A. Palpate for abdominal distention
• B. Send fluid to the lab for analysis
• C. Continue to monitor the fluid output
• D. Clamp the drainage tube for 5 minutes

Correct answer: C

Rationale: Continuing to monitor the fluid output is the appropriate action in this situation. Monitoring the fluid output helps the nurse assess the client's ongoing response to the procedure and detect any sudden changes, such as increased or decreased drainage rate, which could indicate complications. Palpating for abdominal distention, sending fluid to the lab for analysis, or clamping the drainage tube are not necessary actions at this point, as the priority is to monitor the client's condition post-procedure.

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