Nursing Elites

1. A patient is found unconscious in their room with rhythmic jerking of all four extremities and heavy foaming at the mouth. The patient was on seizure precautions with bedrails up and padded. What is the priority action for the nurse to take?

• A. Administer Lorazepam (Ativan)
• B. Turn the patient to his/her side
• C. Call the physician
• D. Suction the patient

Correct answer: B

Rationale: The nurse's priority action should be to turn the patient to his/her side. This position helps maintain an open airway and prevents aspiration of secretions or vomitus. Administering Lorazepam (Ativan) without ensuring a clear airway could lead to further complications. Calling the physician is important, but immediate interventions to protect the airway take precedence. Suctioning the patient may be necessary but should not be the initial action; positioning for airway protection is the priority.

2. During an assessment of a child admitted to the hospital with a probable diagnosis of nephrotic syndrome, what assessment findings should the nurse expect to observe? Select one that applies.

• A. Proteinuria
• B. Weight gain
• C. Decreased serum lipids
• D. Hematuria

Correct answer: A

Rationale: In nephrotic syndrome, the hallmark finding is massive proteinuria due to increased glomerular permeability. This leads to hypoalbuminemia, resulting in generalized edema. Weight gain, not weight loss, is typically seen due to fluid retention. Serum lipids are elevated, not decreased, in nephrotic syndrome. Hematuria, the presence of blood in the urine, is not a typical finding in nephrotic syndrome.

3. The nurse palpates the posterior chest while the patient says 99 and notes absent fremitus. What action should the nurse take next?

• A. Auscultate anterior and posterior breath sounds bilaterally
• B. Encourage the patient to turn, cough, and deep breathe
• C. Review the chest x-ray report for evidence of pneumonia
• D. Palpate the anterior chest and observe for barrel chest

Correct answer: A

Rationale: To assess for tactile fremitus, the nurse should use the palms of the hands to assess for vibration when the patient repeats a word or phrase such as '99'. After noting absent fremitus, the nurse should then auscultate the lungs to assess for the presence or absence of breath sounds. Absent fremitus may be noted with conditions like pneumothorax or atelectasis. The vibration is increased in conditions such as pneumonia, lung tumors, thick bronchial secretions, and pleural effusion. Encouraging the patient to turn, cough, and deep breathe is an appropriate intervention for atelectasis, but assessing breath sounds takes priority. Fremitus is decreased if the hand is farther from the lung or the lung is hyperinflated (barrel chest). Palpating the anterior chest for fremitus is less effective due to the presence of large muscles and breast tissue, making auscultation a more appropriate next step.

4. The nurse is planning care for a client during the acute phase of a sickle cell vasoocclusive crisis. Which of the following actions would be most appropriate?

• A. Fluid restriction to 1000cc per day
• B. Ambulate in the hallway 4 times a day
• C. Administer analgesic therapy as ordered
• D. Encourage increased caloric intake

Correct answer: C

Rationale: Administering analgesic therapy as ordered is the most appropriate action during the acute phase of a sickle cell vasoocclusive crisis. In this phase, the primary focus is on managing the severe pain experienced by the individual. Analgesic therapy helps alleviate the pain and discomfort associated with the crisis. The other options are not the priority during this phase. Fluid restriction is not recommended as hydration is crucial in managing a vasoocclusive crisis. Ambulation may worsen the pain and should be minimized during this phase. Encouraging increased caloric intake is not directly related to managing the acute phase of a vasoocclusive crisis.

5. The nurse provides home care instructions to the parents of a child with celiac disease. The nurse should teach the parents to include which food item in the child's diet?

• A. Rice
• B. Oatmeal
• C. Rye toast
• D. White bread

Correct answer: A

Rationale: In celiac disease, individuals are intolerant to gluten found in wheat, barley, rye, and oats. Therefore, it is crucial to eliminate these grains from the diet. Rice, corn, or millet are safe alternatives for individuals with celiac disease. Oatmeal is generally avoided unless specifically labeled as gluten-free due to possible cross-contamination. Rye toast and white bread contain gluten and should be avoided in celiac disease. Vitamin supplements may also be necessary to address deficiencies caused by dietary restrictions.

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