Nursing Elites

1. Administration of hepatitis B vaccine to a healthy 18-year-old patient has been effective when a specimen of the patient's blood reveals

• A. HBsAg.
• B. anti-HBs
• C. anti-HBc IgG
• D. anti-HBc IgM.

Correct answer: anti-HBs

Rationale: The correct answer is 'anti-HBs'. The presence of surface antibody to HBV (anti-HBs) indicates a successful response to the hepatitis B vaccine. Anti-HBs is a marker of immunity and protection against hepatitis B infection. Choices A, C, and D are incorrect because: A) HBsAg indicates current infection with hepatitis B virus, C) anti-HBc IgG suggests past infection or immunity, and D) anti-HBc IgM is a marker of acute hepatitis B infection.

2. Which pathologic condition is described as 'increased intraocular pressure of the eye'?

• A. Detached Retina
• B. Fovea Centralis
• C. Presbyopia
• D. Glaucoma

Correct answer: D: Glaucoma

Rationale: The correct answer is Glaucoma. Glaucoma is a condition characterized by increased intraocular pressure in the eye, which can lead to optic nerve damage, vision loss, and blindness if left untreated. Detached Retina (A), Fovea Centralis (B), and Presbyopia (C) are not conditions associated with increased intraocular pressure like Glaucoma. Detached Retina is a separation of the retina from its underlying tissue, Fovea Centralis is a part of the retina responsible for sharp central vision, and Presbyopia is an age-related condition affecting near vision due to the loss of flexibility in the eye's lens.

3. An 80-year-old patient is admitted with dyspnea, dependent edema, rales, and distended neck veins. As the nurse monitors the patient, he becomes increasingly short of breath and begins to have cardiac dysrhythmias. The most critical intervention for this patient is to:

• A. Ensure his airway is open and unobstructed.
• B. Apply oxygen to maintain his oxygen saturation above 94%.
• C. Administer Dobutamine to increase cardiac output.
• D. Start an IV for monitoring fluid intake.

Correct answer: Ensure his airway is open and unobstructed.

Rationale: In a patient presenting with dyspnea, dependent edema, rales, distended neck veins, and developing cardiac dysrhythmias, the priority intervention is to ensure the airway is open and unobstructed. Maintaining an open airway is crucial for adequate ventilation and oxygenation, especially in a patient showing signs of impending respiratory distress and cardiac compromise. While applying oxygen to maintain oxygen saturation is important, ensuring airway patency takes precedence as it directly impacts the patient's ability to breathe. Administering Dobutamine may be necessary to improve cardiac output; however, addressing the airway first is essential to prevent further respiratory distress and worsening dysrhythmias. Starting an IV for monitoring fluid intake is not the most critical intervention in this scenario compared to ensuring airway patency and oxygenation.

4. The pediatric nurse caring for a 3-year-old child with cerebral palsy (CP) prepares a home care teaching plan for the caregivers on discharge. Which items will the nurse include in the teaching plan? (Select one that does not apply.)

• A. Apply splints and braces to facilitate muscle control.
• B. Buy toys that are appropriate for the child's abilities.
• C. Encourage the child to perform self-care tasks.
• D. Use skeletal muscle relaxants for short-term control.

Correct answer: Use skeletal muscle relaxants for short-term control.

Rationale: When developing a discharge teaching plan for a child with cerebral palsy (CP), the nurse should focus on strategies to enhance the child's independence and functional abilities. Choices A, B, and C are appropriate interventions to include in the teaching plan for a child with CP. Applying splints and braces can help facilitate muscle control and improve body functioning. Buying toys that are appropriate for the child's abilities can promote engagement and development. Encouraging the child to perform self-care tasks fosters independence and skill development. However, the use of skeletal muscle relaxants for short-term control is not typically a part of routine care for pediatric patients with CP. These medications are usually reserved for specific situations and are not a standard component of home care teaching plans for children with CP.

5. A patient asks a nurse, “My doctor recommended I increase my intake of folic acid. What type of foods contain the highest concentration of folic acid?'

• A. Green vegetables and liver
• B. Yellow vegetables and red meat
• C. Carrots
• D. Milk

Correct answer: Green vegetables and liver

Rationale: Green vegetables and liver are rich sources of folic acid. Green vegetables like spinach, asparagus, and broccoli are high in folic acid content. Liver, especially from chicken or beef, is also a good source of folic acid. Yellow vegetables and red meat (choice B) do not contain as high a concentration of folic acid as green vegetables and liver. Carrots (choice C) are nutritious but do not have the highest concentration of folic acid. Milk (choice D) is not a significant source of folic acid compared to green vegetables and liver.

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