Nursing Elites

1. A 9-year-old boy with tetralogy of Fallot is being discharged following a cardiac catheterization. Which discharge instruction should the nurse provide the parents?

• A. Do not allow the child to return to school for at least one month
• B. Notify the healthcare provider if there is any drainage at the catheterization site
• C. Monitor the child's temperature and report any elevation
• D. Observe for any changes in the child's color or energy level

Correct answer: B

Rationale: The correct answer is to notify the healthcare provider if there is any drainage at the catheterization site. Drainage at the site can be a sign of infection, which needs prompt evaluation and treatment. Choices A, C, and D are not as crucial as identifying and reporting any drainage, which is more directly related to potential complications post-cardiac catheterization.

2. A 20-year-old female client tells the nurse that her menstrual periods occur about every 28 days, and her breasts are quite tender when her menstrual flow is heavy. She also states that she performs her breast self-examination (BSE) on the first day of every month. What action should the nurse implement in response to the client's statements?

• A. Remind the client that it is also important to schedule an annual mammogram
• B. Refer the client to a nurse practitioner for an in-depth review of the BSE procedure
• C. Encourage the client to perform BSE 2 to 3 days after the menstrual period ends
• D. Instruct the client to continue with her regular monthly exams as she is doing

Correct answer: C

Rationale: The correct response is to encourage the client to perform breast self-examination (BSE) 2 to 3 days after her menstrual period ends. This timing is important because breasts are least tender during this phase of the menstrual cycle, allowing for a more effective examination. Choice A is incorrect because while scheduling an annual mammogram is important, the immediate concern is the timing of BSE. Choice B is incorrect as the client's BSE practice just needs a slight adjustment in timing, not an in-depth review. Choice D is incorrect as the client should perform BSE when her breasts are least tender for optimal detection of any abnormalities.

3. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 4 liters per minute via nasal cannula. The client becomes lethargic and confused. What action should the nurse take first?

• A. Decrease the oxygen flow rate
• B. Increase the oxygen flow rate
• C. Encourage the client to cough and deep breathe
• D. Monitor the client's oxygen saturation level

Correct answer: A

Rationale: In this scenario, the priority action for the nurse is to decrease the oxygen flow rate. Clients with COPD are sensitive to high levels of oxygen and can develop oxygen toxicity, leading to symptoms like lethargy and confusion. Decreasing the oxygen flow rate helps prevent this complication. Increasing the oxygen flow rate would worsen the client's condition. Encouraging coughing and deep breathing may not address the immediate issue of oxygen toxicity. While monitoring the client's oxygen saturation level is important, taking action to address the oxygen toxicity by decreasing the flow rate is the priority in this situation.

4. The client is being taught how to take alendronate (Fosamax) for osteoporosis treatment. Which statement indicates that the client needs further teaching?

• A. I should take this medication at bedtime
• B. I will need to take this medication for at least 3 years
• C. I should sit up for 30 minutes after taking the medication
• D. I should take this medication with a full glass of water

Correct answer: A

Rationale: The correct answer is A because taking Fosamax at bedtime is incorrect. It should be taken in the morning with a full glass of water to prevent esophageal irritation. Choice B is correct; alendronate is typically taken for several years to treat osteoporosis. Choice C is correct as remaining upright for 30 minutes after taking Fosamax helps prevent esophageal irritation. Choice D is also correct as taking alendronate with a full glass of water is necessary to ensure proper absorption.

5. The nurse is making assignments for a new graduate from a practical nursing program who is orienting to the unit. Because the unit is particularly busy this day, there will be little time to provide supervision of this new employee. Which client is the best for the nurse to assign to this newly graduated practical nurse?

• A. Whose discharge has been delayed because of a postoperative infection
• B. With poorly controlled type 2 diabetes who is on a sliding scale for insulin administration
• C. Newly admitted with a head injury who requires frequent assessments
• D. Receiving IV heparin that is regulated based on protocol

Correct answer: A

Rationale: The correct answer is A because a client with a stable infection requires less supervision and is suitable for the new nurse. Choice B involves insulin administration for a client with poorly controlled diabetes, which may require more experience and supervision. Choice C involves a newly admitted patient with a head injury who requires frequent assessments, indicating a need for close monitoring. Choice D involves a patient receiving IV heparin, which requires precise monitoring and adjustment based on protocol, making it a higher-risk assignment for a new nurse without close supervision.

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