Nursing Elites

1. After changing to a new brand of laundry detergent, an adult male reports that he has a fine itchy rash. Which assessment finding warrants immediate intervention by the nurse?

• A. Bilateral Wheezing
• B. Urticaria
• C. Peripheral edema
• D. Elevated blood pressure

Correct answer: B

Rationale: The correct answer is B: Urticaria. An itchy rash following a change in detergent may indicate an allergic reaction, specifically urticaria (hives), which requires immediate attention. Urticaria can be a sign of a severe allergic reaction, such as anaphylaxis. Bilateral wheezing (choice A) may suggest respiratory issues like asthma but is not directly related to the skin rash. Peripheral edema (choice C) and elevated blood pressure (choice D) are not typically associated with an allergic reaction to laundry detergent and would not be the priority assessment findings in this scenario.

2. The parents of a child who had surgical repair of a myelomeningocele are being taught how to change an occlusive dressing on the child’s back. Which statement by the parents indicates that they understand this procedure?

• A. When changing the dressing, the tape should be removed slowly to prevent trauma to the skin
• B. To prevent infection, the dressing should be kept dry to avoid excess moisture
• C. The skin incision should be kept moist to promote healing and prevent dryness
• D. The incision should be protected from fecal contamination by an intact dressing

Correct answer: D

Rationale: The correct answer is D because protecting the incision from fecal contamination is essential to prevent infection and promote healing in a child with a myelomeningocele. This is crucial as fecal matter can introduce harmful bacteria to the wound. Choice A is incorrect as removing the tape slowly to prevent trauma to the skin is a general guideline but not specific to preventing infection. Choice B is incorrect because keeping the dressing dry can lead to complications as the wound needs a moist environment to heal properly. Choice C is incorrect as keeping the skin incision moist may promote infection and delay healing, making it an incorrect statement for postoperative care.

3. What is the primary focus of postoperative nursing care for the client with colon trauma?

• A. Monitoring for elevated coagulation studies
• B. Observation for and prevention of fistulas
• C. Monitoring for signs of hyponatremia
• D. Observation for and prevention of infection

Correct answer: D

Rationale: The correct answer is D: Observation for and prevention of infection. Postoperative nursing care for a client with colon trauma primarily focuses on preventing infections. Clients with colon trauma are at high risk for infections due to the disruption of the intestinal barrier. Monitoring for signs of infection, maintaining proper wound care, administering antibiotics as prescribed, and implementing strict aseptic techniques are essential in preventing postoperative infections. Choices A, B, and C are incorrect because elevated coagulation studies, fistulas, and hyponatremia are not the primary concerns in the immediate postoperative period for a client with colon trauma.

4. To reduce the risk of symptoms exacerbation for a client with multiple sclerosis (MS), which instructions should the nurse include in the client’s discharge plan? (Select all that apply).

• A. Practice relaxation exercises
• B. Limit fluids to avoid bladder distention
• C. Space activities to allow for rest periods
• D. Avoid persons with infections

Correct answer: A

Rationale: The correct instruction to include in the discharge plan for a client with MS to reduce symptom exacerbation is practicing relaxation exercises. Relaxation exercises can help manage MS symptoms by reducing stress. Limiting fluids to avoid bladder distention is not appropriate as adequate hydration is essential for overall health and helps prevent complications like urinary tract infections. While spacing activities to allow for rest periods can be beneficial for general well-being, it is not directly related to symptom exacerbation in MS. Avoiding persons with infections is important to prevent infections, but it is not specifically targeted at reducing MS symptom exacerbation.

5. A young female adult wanders into the Emergency Department. She is disheveled and confused and states, 'My date must have put something in my drink. He took my car, and I think he raped me. I don't exactly remember, but I know he hurt me.' How should the nurse respond?

• A. Did you try to resist or fight back when you felt uncomfortable?
• B. He hurt you? Can you elaborate on what happened?
• C. It is okay to cry, but first, let's address your injuries and the situation.
• D. Yes, I can see. Tell me more about what you remember.

Correct answer: D

Rationale: The correct response is to encourage the patient to share more about what she remembers. This approach helps gather crucial information, supports the patient in a non-judgmental manner, and allows the nurse to provide appropriate care. Choice A has been revised to be more sensitive by asking about resistance when feeling uncomfortable rather than placing blame. Choice B has been adjusted to show empathy and request more details without questioning the patient's account. Choice C, although empathetic, does not address the immediate need to collect information and support the patient.

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