Nursing Elites

1. A patient asks the nurse why they must have a heparin injection. What is the nurse's best response?

• A. Heparin will dissolve clots that you have.
• B. Heparin will reduce the platelets that make your blood clot.
• C. Heparin will work better than warfarin.
• D. Heparin will prevent new clots from developing.

Correct answer: D

Rationale: The correct answer is D: 'Heparin will prevent new clots from developing.' Heparin is an anticoagulant medication that helps prevent the formation of new blood clots. It does not dissolve existing clots (choice A), reduce platelets (choice B), or necessarily work 'better' than warfarin (choice C) but rather functions differently. The primary action of heparin is to prevent the development of new clots, especially in conditions where clot formation is a concern.

2. A child is prescribed baclofen (Lioresal) via intrathecal pump to treat severe muscle spasms related to cerebral palsy. What teaching does the nurse provide the child and parents?

• A. Do not let this prescription run out.
• B. The medication may cause gingival hyperplasia.
• C. Periodic serum drug levels are needed.
• D. Watch for excessive facial hair growth.

Correct answer: A

Rationale: The correct teaching for the child and parents when a child is prescribed baclofen via an intrathecal pump is to not let the prescription run out. Abrupt discontinuation of intrathecal baclofen can lead to severe effects like high fever, altered mental status, and rebound spasticity and muscle rigidity. It is crucial for the parents to ensure there is always an adequate supply of this medication to prevent these adverse effects. Choices B and D are incorrect because gingival hyperplasia and hirsutism are side effects associated with phenytoin (Dilantin), not baclofen. Choice C is incorrect as serum drug levels are not typically monitored for intrathecal medications.

3. The parents of a newborn with hypospadias are reviewing the treatment plan with the nurse. Which statement by the parents indicates their understanding of the plan?

• A. Caution should be used when straddling my infant on a hip.
• B. Vital signs should be taken daily to check for bladder infection.
• C. Catheterization will be necessary when my infant does not void.
• D. Circumcision has been delayed to save tissue for surgical repair.

Correct answer: D

Rationale: Hypospadias is a congenital defect involving abnormal placement of the urethral orifice of the penis. In hypospadias, the urethral orifice is located below the glans penis along the ventral surface. It's important not to circumcise the infant, as the dorsal foreskin tissue will be required for surgical repair of the hypospadias. Option A is unrelated to the treatment plan for hypospadias. Option B is not directly related to the surgical repair of hypospadias. Option C is not a routine part of the treatment plan for hypospadias, as catheterization is usually managed by healthcare professionals.

4. When asked to describe in layman's terms an overview of the condition called osteomyelitis, what would be the nurse's best response?

• A. Osteomyelitis is a gradual breakdown and weakening of your bones. It's most often age-related.
• B. Osteomyelitis is caused by not having enough Vitamin D, which in turn causes your bones to be softer and demineralized.
• C. Osteomyelitis is an infection in the bone. It can be caused by bacteria reaching your bone from outside or inside your body.
• D. This is a question that should be directed to your healthcare provider.

Correct answer: C

Rationale: Osteomyelitis is an infection in the bone that can be caused by bacteria reaching the bone either from outside the body (such as through an open fracture) or inside the body (such as through the bloodstream). This response provides a concise and accurate explanation of osteomyelitis, making it the best choice. Choices A and B provide inaccurate information about the condition, attributing it to age-related bone breakdown and Vitamin D deficiency, which are not correct causes of osteomyelitis. Choice D deflects the question instead of providing the patient with a clear explanation, making it an inappropriate response.

5. When assessing the respiratory system of an older patient, which finding indicates that the nurse should take immediate action?

• A. Weak cough effort
• B. Barrel-shaped chest
• C. Dry mucous membranes
• D. Bilateral crackles at lung bases

Correct answer: D

Rationale: Bilateral crackles at lung bases indicate a potential acute issue like heart failure. Immediate action is necessary in this situation. The nurse should conduct further assessments such as oxygen saturation and inform the healthcare provider promptly. A barrel-shaped chest and hyperresonance to percussion are typical signs of aging and do not require immediate action. A weak cough effort is common in older patients due to age-related changes, and dry mucous membranes are also expected in older individuals. While these findings may warrant further evaluation, they do not demand immediate action like bilateral crackles at lung bases.

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