Nursing Elites

1. A toddler presenting with a history of intermittent skin rashes, hives, abdominal pain, and vomiting that occurs after ingesting milk products arrives at the clinic accompanied by the parents. Which type of testing should the nurse educate the toddler's family about?

• A. Complete blood count
• B. Lactose tolerance test
• C. Skin allergy testing
• D. Serum immunoglobulin E

Correct answer: D

Rationale: The correct answer is D, Serum immunoglobulin E (IgE) testing. This test can help diagnose food allergies, including milk protein allergies, in toddlers presenting with symptoms like skin rashes, hives, abdominal pain, and vomiting after consuming milk products. Skin allergy testing is used for allergies but may not be suitable for this age group due to developmental factors. Lactose intolerance, which is different from a milk allergy, is assessed through a lactose tolerance test, not IgE testing. A complete blood count (CBC) would not provide specific information related to food allergies.

2. A client is receiving a blood transfusion and develops a fever. What is the nurse's first action?

• A. Administer an antipyretic as prescribed.
• B. Stop the transfusion and notify the healthcare provider.
• C. Slow the rate of the transfusion.
• D. Continue the transfusion and reassess in 15 minutes.

Correct answer: B

Rationale: The correct first action when a client receiving a blood transfusion develops a fever is to stop the transfusion and notify the healthcare provider. This is crucial to prevent further reactions and ensure prompt intervention. Administering an antipyretic (Choice A) may mask symptoms and delay appropriate treatment. Slowing the rate of the transfusion (Choice C) might not address the underlying cause of the fever. Continuing the transfusion and reassessing in 15 minutes (Choice D) could worsen the client's condition if there is a severe reaction occurring.

3. The nurse is providing care for a client with a percutaneous endoscopic gastrostomy (PEG) tube. Which intervention should the nurse implement to prevent complications associated with the tube?

• A. Elevate the head of the bed to 15 degrees during feedings
• B. Aspirate gastric contents before administering medications
• C. Clamp the tube between feedings
• D. Flush the tube with water before and after feedings

Correct answer: D

Rationale: Flushing the PEG tube with water before and after feedings helps prevent clogging and maintains tube patency. Proper flushing is essential for avoiding complications related to tube blockages. Elevating the head of the bed is important for preventing aspiration during and after feedings, not specifically related to PEG tube complications. Aspirating gastric contents before administering medications is not routinely recommended for PEG tube care. Clamping the tube between feedings can lead to tube occlusion and is not a standard practice in PEG tube care.

4. A female client with acute respiratory distress syndrome (ARDS) is sedated and on a ventilator with 50% FIO2. What assessment finding warrants immediate intervention?

• A. Assess the client’s lung sounds bilaterally.
• B. Diminished left lower lobe sounds.
• C. Monitor ventilator settings for changes in oxygen levels.
• D. Increased sputum production and shortness of breath.

Correct answer: B

Rationale: Diminished breath sounds in a sedated client with ARDS and on a ventilator indicate collapsed alveoli, which requires immediate intervention, such as chest tube insertion, to prevent further lung damage. Assessing bilateral lung sounds (Choice A) is important but not as urgent as identifying diminished sounds in a specific location. Monitoring ventilator settings (Choice C) is essential but does not directly address the immediate need for intervention due to diminished breath sounds. Increased sputum production and shortness of breath (Choice D) may indicate other issues but are not specific to the urgency of addressing diminished breath sounds in ARDS.

5. While assessing a client who is admitted with heart failure and pulmonary edema, the nurse identifies dependent peripheral edema, an irregular heart rate, and a persistent cough that produces pink blood-tinged sputum. After initiating continuous telemetry and positioning the client, which intervention should the nurse implement?

• A. Administer prescribed diuretics
• B. Prepare for intubation
• C. Notify the healthcare provider immediately
• D. Obtain sputum sample

Correct answer: D

Rationale: The client's cough producing pink, frothy sputum is indicative of pulmonary edema, which needs immediate treatment. Obtaining a sputum sample helps identify any infection that may be contributing to the pulmonary issues. Administering diuretics is essential in managing pulmonary edema but obtaining a sputum sample should take priority. Intubation may be necessary in severe cases but is not the initial intervention. Notifying the healthcare provider is important, but immediate action to diagnose and treat the condition is crucial.

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