Nursing Elites

1. A client with a history of asthma and bronchitis arrives at the clinic with shortness of breath, productive cough with thickening mucus, and the inability to walk up a flight of stairs without experiencing breathlessness. Which action is most important for the nurse to instruct the client about self-care?

• A. Increase the daily intake of oral fluids to liquefy secretions
• B. Avoid crowded enclosed areas to reduce pathogen exposure
• C. Call the clinic if undesirable side effects of medications occur
• D. Teach anxiety reduction methods for feelings of suffocation

Correct answer: A

Rationale: Increasing fluid intake is crucial as it helps to thin mucus secretions, making them easier to expectorate. This can alleviate the client's symptoms of shortness of breath and productive cough. Option B is not the most important action in this scenario, as it does not directly address the client's respiratory distress. Option C, while important, focuses on medication side effects rather than addressing the immediate breathing difficulties. Option D, teaching anxiety reduction methods, is not the priority when the client's main concern is respiratory distress.

2. A healthcare worker with no known exposure to tuberculosis has received a Mantoux tuberculosis skin test. The nurse's assessment of the test after 62 hours indicates 5mm of erythema without induration. Which is the best initial nursing action?

• A. Review the healthcare worker's history for possible exposure to TB.
• B. Instruct the healthcare worker to return for a repeat test in 1 week.
• C. Refer the healthcare worker to a healthcare provider for isoniazid (INH) therapy.
• D. Document negative results in the healthcare worker's medical record.

Correct answer: D

Rationale: A Mantoux tuberculosis skin test without induration is considered negative. In this case, with 5mm of erythema and no induration, the result is negative, indicating no current infection. The best initial nursing action is to document these negative results in the healthcare worker's medical record. Reviewing the history for possible exposure to TB is unnecessary as the test result is negative. Instructing the healthcare worker to return for a repeat test or referring for INH therapy is not warranted when the test is negative.

3. What most influences the severity of respiratory distress syndrome (RDS)?

• A. Poor cough and gag reflex
• B. The gestational age at birth
• C. Administering high concentrations of oxygen
• D. The sex of the infant

Correct answer: B

Rationale: The correct answer is B. The gestational age at birth most influences the severity of respiratory distress syndrome (RDS). RDS is caused by a deficiency of surfactant and it occurs almost exclusively in preterm, low-birth weight infants. Therefore, the gestational age at birth is a key factor in determining the likelihood and severity of RDS. Choices A, C, and D are incorrect as they do not directly relate to the primary factor influencing the severity of RDS.

4. The parents of a child who has had a myringotomy are instructed by the nurse to place the child in which position?

• A. Supine
• B. On the affected side
• C. On the unaffected side
• D. In Trendelenburg's position

Correct answer: B

Rationale: Placing the child on the affected side after a myringotomy facilitates ear drainage. This position helps prevent accumulation of fluids in the ear canal, aiding in the healing process. Placing the child in the supine position (Choice A) or on the unaffected side (Choice C) may not be as effective in promoting drainage. The Trendelenburg's position (Choice D) with the head lower than the body is used for conditions requiring increased venous return, not for post-myringotomy care.

5. The health care provider is treating a child with meningitis with a course of antibiotic therapy. When should the nurse expect the child to be out of isolation?

• A. When the course of antibiotics is complete
• B. When a negative CNS culture is obtained
• C. When the antibiotics have been initiated for 24 hours
• D. When the child has no symptoms of the disease

Correct answer: C

Rationale: The correct answer is C because a child with bacterial meningitis should be isolated for at least 24 hours until antibiotic therapy has been initiated. This period allows the antibiotics to start working against the infection, reducing the risk of spreading it to others. Choice A is incorrect because isolation is not solely based on completing the course of antibiotics; the initiation is crucial. Choice B is incorrect as waiting for a negative CNS culture may take longer and delay necessary precautions. Choice D is incorrect as symptom resolution does not guarantee the eradication of the infection and may still pose a risk of transmission.

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