Nursing Elites

1. In a long term rehabilitation care unit a client with spinal cord injury complains of a pounding headache. The client is sitting in a wheelchair watching television in the assigned room. Further assessment by the nurse reveals excessive sweating, a splotchy rash, pilomotor erection, facial flushing, congested nasal passages and a heart rate of 50. The nurse should do which action next?

• A. Take the client's respirations, blood pressure (BP), temperature and then pupillary responses
• B. Place the client into the bed and administer the ordered PRN analgesic
• C. Check the client for bladder distention and the client's urinary catheter for kinks
• D. Turn the television off and then assist client to use relaxation techniques

Correct answer: C

Rationale: These symptoms suggest autonomic dysreflexia, often triggered by bladder distention.

2. The home health care agency can expect to obtain Medicare reimbursement for which home visit performed by a registered nurse (RN) or a practical nurse (PN)?

• A. Assessment of the speech pattern of a mobile adult who had a mild stroke last year.
• B. Safety teaching for an older male client whose wife complains that he uses an unsafe ladder while painting.
• C. Wound care for a client who had a postoperative infection following abdominal surgery two weeks ago.
• D. Evaluation of crutch use by a 65-year-old male client who broke his tibia while snow skiing.

Correct answer: C

Rationale: The correct answer is C because wound care for a postoperative infection is a skilled service that qualifies for Medicare reimbursement. Choices A, B, and D involve assessments, teaching, and evaluation, which may not meet the criteria for Medicare reimbursement as they do not directly involve a skilled nursing service related to a postoperative condition.

3. When providing nursing care to a client receiving oxygen therapy via a nasal cannula, which of the following interventions would be appropriate?

• A. Ensure that adequate mist is supplied
• B. Inspect the nares and ears for skin breakdown
• C. Lubricate the tips of the cannula before insertion
• D. Maintain sterile technique when handling the cannula

Correct answer: B

Rationale: The correct answer is to inspect the nares and ears for skin breakdown. This is important because the nasal cannula can cause skin breakdown due to prolonged use and friction. Ensuring that the skin is intact helps prevent complications. Choice A is incorrect as oxygen therapy via a nasal cannula does not involve mist. Choice C is incorrect as lubricating the tips of the cannula is not a standard practice and may lead to complications. Choice D is incorrect because while cleanliness is important, maintaining sterile technique is not necessary for handling a nasal cannula in this context.

4. What is the main objective of the Expanded Program on Immunization (EPI)?

• A. Provide healthcare to all individuals
• B. Reduce child mortality
• C. Eliminate vaccine-preventable diseases
• D. Promote healthy lifestyles

Correct answer: C

Rationale: The main objective of the Expanded Program on Immunization (EPI) is to eliminate vaccine-preventable diseases. While providing healthcare to all individuals and reducing child mortality are important goals, the primary focus of EPI is specifically on preventing diseases through immunization. Promoting healthy lifestyles, although beneficial, is not the primary aim of the EPI.

5. The nurse is administering the measles, mumps, rubella (MMR) vaccine to a 12-month-old child during the well-baby visit. Which age range should the nurse advise the parents to plan for their child to receive the MMR booster based on the current recommendations and guidelines by the Center for Disease Control (CDC)?

• A. 13 to 18 years of age.
• B. 11 to 12 years of age.
• C. 18 to 24 months of age.
• D. 4 to 6 years of age.

Correct answer: D

Rationale: The correct answer is D: 4 to 6 years of age. The CDC recommends the MMR booster for children in this age group. Choice A (13 to 18 years of age) is incorrect as it is not the recommended age range for the MMR booster. Choice B (11 to 12 years of age) is also incorrect as it does not align with the CDC guidelines for the MMR booster. Choice C (18 to 24 months of age) is not the correct age range for the MMR booster according to CDC recommendations.

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