Nursing Elites

1. A nurse in a pediatric clinic is teaching a newly hired nurse about the varicella roster. Which of the following information should the nurse include?

• A. Children who have varicella are contagious until vesicles are crusted
• B. Children who have varicella should receive the herpes zoster vaccination
• C. Children who have varicella should be placed in droplet precautions
• D. Children who have varicella are contagious 4 days before the first vesicle eruption

Correct answer: A

Rationale: The correct answer is A. Children with varicella are contagious until the vesicles crust over, which is important for preventing transmission. Choice B is incorrect as varicella and herpes zoster are caused by different viruses, so the varicella vaccine is given to prevent varicella, not herpes zoster. Choice C is incorrect because varicella is primarily spread through respiratory secretions, so airborne precautions are recommended, not droplet precautions. Choice D is incorrect as children with varicella are contagious even before the first vesicle eruption, not just 4 days before.

2. A nurse is caring for a client who is experiencing dysphagia. Which of the following interventions should the nurse implement?

• A. Administer thickened liquids.
• B. Provide small bites of food.
• C. Encourage the client to eat quickly to avoid fatigue.
• D. Have the client lie supine after meals.

Correct answer: A

Rationale: The correct intervention for a client with dysphagia is to administer thickened liquids. Thickened liquids help prevent aspiration, which is a common risk for clients with swallowing difficulties. Providing small bites of food (choice B) can help, but the priority is to modify the liquid consistency. Encouraging the client to eat quickly (choice C) is not recommended as it may increase the risk of aspiration and fatigue. Having the client lie supine after meals (choice D) can actually increase the risk of aspiration, especially in clients with dysphagia.

3. A nurse is preparing to administer an intermittent tube feeding to a client who has a gastrostomy tube. Which of the following actions should the nurse take?

• A. Flush the tube with 10 mL of water after feeding
• B. Flush the tube with 30 mL of water before feeding
• C. Place the client in a left lateral position
• D. Place the feeding bag 61 cm (24 in) above the client's abdomen

Correct answer: B

Rationale: The correct action for the nurse to take when preparing to administer an intermittent tube feeding to a client with a gastrostomy tube is to flush the tube with 30 mL of water before feeding. This step helps ensure the patency of the tube by clearing any blockages or residuals. Choice A is incorrect because flushing after feeding would not prevent clogging before the feeding. Choice C is unrelated to tube feeding administration. Choice D is incorrect as the height for the feeding bag is usually recommended to be at or below the level of the stomach to prevent complications like aspiration.

4. A nurse is caring for a client who has a pulmonary embolism. Which of the following findings indicates the effectiveness of the treatment?

• A. A chest x-ray reveals increased density in all lung fields.
• B. The client reports feeling less anxious.
• C. Diminished breath sounds are auscultated bilaterally.
• D. ABG results include pH 7.48, PaO2 77 mm Hg, and PaCO2 47 mm Hg.

Correct answer: B

Rationale: The correct answer is B. In a client with a pulmonary embolism, improvement in anxiety levels can indicate the effectiveness of treatment as it suggests better oxygenation and perfusion. Choices A, C, and D do not directly reflect the effectiveness of treatment for a pulmonary embolism. Increased density in all lung fields on a chest x-ray may indicate worsening of the condition, diminished breath sounds suggest impaired lung function, and ABG results with a pH of 7.48, PaO2 of 77 mm Hg, and PaCO2 of 47 mm Hg do not specifically indicate treatment effectiveness for a pulmonary embolism.

5. Which lab value is critical for monitoring warfarin therapy?

• A. Monitor INR
• B. Monitor platelet count
• C. Monitor sodium levels
• D. Monitor calcium levels

Correct answer: A

Rationale: The correct answer is A: Monitor INR. INR (International Normalized Ratio) is crucial for monitoring warfarin therapy as it helps assess the therapeutic effectiveness and bleeding risks associated with the medication. INR measures the clotting tendency of blood, which is essential in determining the appropriate dosage of warfarin. Monitoring platelet count (B), sodium levels (C), or calcium levels (D) is not primarily used for assessing warfarin therapy. Platelet count is more relevant in assessing bleeding disorders, while sodium and calcium levels are typically monitored for different medical conditions unrelated to warfarin therapy.

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