Nursing Elites

1. When reassigned to the emergency department, a nurse should understand that gastric lavage is a priority in which situation?

• A. An infant who has been identified to have botulism
• B. A toddler who ate a number of ibuprofen tablets
• C. A preschooler who swallowed powdered plant food
• D. A school-aged child who took a handful of vitamins

Correct answer: A

Rationale: The correct answer is A because gastric lavage is a priority for infants with botulism to remove toxins from the stomach. Botulism is a serious condition caused by a toxin produced by Clostridium botulinum bacteria. Gastric lavage helps in removing the toxin from the stomach. Choice B is incorrect because gastric lavage is not typically indicated for ibuprofen ingestion. Choice C is incorrect because gastric lavage is not the first-line treatment for ingesting powdered plant food. Choice D is incorrect because gastric lavage is not routinely performed for vitamin ingestion.

2. The nurse is discussing with a group of students the disease Kawasaki. What statement made by a student about Kawasaki disease is incorrect?

• A. It is also called mucocutaneous lymph node syndrome because it affects the mucous membranes (inside the mouth, throat, and nose), skin, and lymph nodes.
• B. In the second phase of the disease, findings include peeling of the skin on the hands and feet with joint and abdominal pain.
• C. Kawasaki disease occurs most often in boys, children younger than age 5, and children of Hispanic descent.
• D. Initially findings are a sudden high fever, usually above 104 degrees Fahrenheit, which lasts 1 to 2 weeks.

Correct answer: C

Rationale: The correct answer is C. Kawasaki disease occurs most often in boys and children younger than age 5, but there is no specific predisposition to children of Hispanic descent. Choice A is accurate, as Kawasaki disease does affect mucous membranes, skin, and lymph nodes. Choice B is correct, as peeling of the skin on the hands and feet with joint and abdominal pain are findings in the second phase of the disease. Choice D is accurate since initially, there is a sudden high fever that lasts 1 to 2 weeks.

3. A nurse is to collect a sputum specimen for acid-fast bacillus (AFB) from a client. Which action should the nurse take first?

• A. Ask the client to cough sputum into a container
• B. Have the client take several deep breaths
• C. Provide an appropriate specimen container
• D. Assist with oral hygiene

Correct answer: D

Rationale: Assisting with oral hygiene is the essential initial step before collecting a sputum specimen for acid-fast bacillus (AFB) to prevent contamination of the sample. Ensuring the client's mouth is clean reduces the risk of introducing unwanted bacteria into the specimen. Asking the client to cough sputum into a container, having the client take deep breaths, and providing a specimen container are important steps in the specimen collection process, but they should follow ensuring proper oral hygiene.

4. The nurse assesses a 72-year-old client who was admitted for right-sided congestive heart failure. Which of the following would the nurse anticipate finding?

• A. Decreased urinary output
• B. Jugular vein distention
• C. Pleural effusion
• D. Bibasilar crackles

Correct answer: B

Rationale: In right-sided congestive heart failure, the nurse would anticipate finding jugular vein distention. This occurs due to increased venous pressure, leading to the distention of the jugular veins in the neck. Choices A, C, and D are incorrect. Decreased urinary output is not typically associated with right-sided heart failure; pleural effusion and bibasilar crackles are more commonly seen in conditions like left-sided heart failure.

5. A newly admitted adult client has a diagnosis of hepatitis A. The charge nurse should reinforce to the staff members that the most significant routine infection control strategy, in addition to hand washing, to be implemented is which of these?

• A. Apply appropriate signs outside and inside the room
• B. Apply a mask with a shield if there is a risk of fluid splash
• C. Wear a gown to change soiled linens from incontinence
• D. Have gloves on while handling bedpans with feces

Correct answer: D

Rationale: The correct answer is to have gloves on while handling bedpans with feces. Hepatitis A is transmitted through the fecal-oral route, and using gloves during such direct contact with feces is crucial in preventing the transmission of the infection. Choice A is not directly related to infection control for hepatitis A. Choice B is more relevant to preventing droplet transmission rather than fecal-oral transmission. Choice C is important for preventing contact transmission from soiled linens but is not as directly related to the mode of transmission of hepatitis A as using gloves when handling feces.

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