Nursing Elites

1. A nurse is teaching postoperative care to the parents of a toddler following a cleft palate repair. Which of the following should be included in the teaching?

• A. Provide an orthodontic pacifier for comfort
• B. Offer fluids using a straw
• C. Cleanse the suture line with a cotton-tip swab
• D. Remove elbow splints periodically to perform range of motion

Correct answer: D

Rationale: The correct answer is D. Elbow splints are utilized to prevent the child from touching the surgical site. However, it is essential to remove them periodically to conduct range-of-motion exercises to prevent joint stiffness. Choices A, B, and C are incorrect because providing an orthodontic pacifier, offering fluids using a straw, and cleansing the suture line with a cotton-tip swab are not directly related to postoperative care following a cleft palate repair.

2. A community health nurse is teaching a group of clients about first aid for different types of wounds. Which of the following client statements indicates an understanding of the teaching?

• A. I should apply clean dressings over blood-saturated dressings and hold pressure.
• B. I will rinse the wound with hot water to cleanse it.
• C. I can remove the dressing once the bleeding stops.
• D. I should apply antibiotic ointment directly to the wound.

Correct answer: A

Rationale: The correct answer is A because applying clean dressings over blood-saturated dressings and holding pressure helps prevent disruption of wound tissue, aiding in the clotting process and controlling bleeding. Choice B is incorrect as rinsing a wound with hot water can cause further tissue damage. Choice C is incorrect as the dressing should not be removed once applied as it can disrupt the formation of a clot. Choice D is incorrect as antibiotic ointment should not be applied directly to the wound during initial first aid.

3. A nurse on an acute med-surgical unit is performing assessments on a group of clients. Which is the highest priority?

• A. Client with surgical hypoparathyroidism and positive Trousseau's sign
• B. Client with Clostridium difficile and acute diarrhea
• C. Client with acute kidney injury and low urine specific gravity
• D. Client with oral cancer and reports a sore on his gums

Correct answer: A

Rationale: The correct answer is A. A positive Trousseau's sign indicates hypocalcemia, which can lead to life-threatening complications like tetany or laryngospasm, making it the highest priority. Choices B, C, and D, while important, do not pose immediate life-threatening risks compared to the potential complications of severe hypocalcemia seen in a client with surgical hypoparathyroidism and a positive Trousseau's sign.

4. A nurse is caring for a client who has an indwelling urinary catheter. What should the nurse identify as a catheter occlusion?

• A. Pain during urination
• B. Bladder distention
• C. Cloudy urine
• D. Blood in the catheter tube

Correct answer: B

Rationale: The correct answer is B: Bladder distention. Bladder distention indicates that the bladder is full and there is impaired elimination, which could be caused by catheter occlusion. Pain during urination (choice A) is not typically associated with catheter occlusion but may indicate a urinary tract infection. Cloudy urine (choice C) can be a sign of infection but is not specific to catheter occlusion. Blood in the catheter tube (choice D) may indicate trauma during catheter insertion but is not a typical finding in catheter occlusion.

5. A nurse is admitting a client who has meningococcal meningitis. What should the nurse do first?

• A. Initiate droplet precautions
• B. Start intravenous antibiotics
• C. Perform a complete assessment
• D. Notify the healthcare provider

Correct answer: A

Rationale: The first priority when admitting a client with meningococcal meningitis is to initiate droplet precautions. This is essential to prevent the transmission of the infection to others, as meningococcal meningitis is highly contagious through respiratory droplets. Starting intravenous antibiotics or performing a complete assessment can follow, but the immediate concern is to implement infection control measures. Notifying the healthcare provider should also be done but is not the first action to take in this situation.

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