Nursing Elites

1. The home health nurse visits a male client to provide wound care and finds the client lethargic and confused. His wife states he fell down the stairs two (2) hours ago. The nurse should

• A. Place a call to the client's healthcare provider for instructions
• B. Send him to the emergency room for evaluation
• C. Reassure the client's wife that the symptoms are transient
• D. Instruct the client's wife to call the doctor if his symptoms become worse

Correct answer: B

Rationale: In this scenario, the client is presenting with concerning symptoms of lethargy and confusion after a fall. These symptoms could indicate a serious underlying issue, such as a head injury or internal bleeding. The nurse's priority is to ensure the client receives immediate evaluation and treatment to prevent any further harm. Option B is the correct choice as it emphasizes the urgency of the situation. Choices A, C, and D are incorrect because they do not address the critical nature of the client's condition. Contacting the healthcare provider, reassuring the wife, or waiting for symptoms to worsen could delay necessary medical intervention.

2. What nursing intervention demonstrates that the nurse understands the priority nursing diagnosis when caring for oral cancer patients with extensive tumor involvement and/or a high amount of secretions?

• A. The nurse uses a pen pad to communicate with the patient
• B. The nurse provides oral care every 2 hours
• C. The nurse listens for bowel sounds every 4 hours
• D. The nurse suctions as needed and elevates the head of the bed

Correct answer: D

Rationale: The correct answer is to suction as needed and elevate the head of the bed. This intervention is crucial for managing Ineffective Airway Clearance, which is the priority nursing diagnosis in oral cancer patients with extensive tumor involvement and/or a high amount of secretions. Suctioning helps clear secretions that may obstruct the airway, while elevating the head of the bed promotes optimal respiratory function. Providing oral care every 2 hours may be important for overall oral health but is not directly related to addressing the priority diagnosis. Listening for bowel sounds every 4 hours is more relevant to gastrointestinal assessment and not specific to managing airway clearance issues in oral cancer patients.

3. During an admission assessment on a 2-year-old child diagnosed with nephrotic syndrome, the nurse notes that which characteristic is most commonly associated with this syndrome?

• A. Hypertension
• B. Generalized edema
• C. Increased urinary output
• D. Frank, bright red blood in the urine

Correct answer: B

Rationale: Nephrotic syndrome in children is characterized by massive proteinuria, hypoalbuminemia, hyperlipidemia, and edema. The most common manifestation is generalized edema due to protein loss in the urine, leading to decreased plasma oncotic pressure. This results in fluid shifting into the interstitial spaces, causing edema. Hypertension is not a typical feature of nephrotic syndrome in children. Increased urinary output is not a common finding; instead, children with nephrotic syndrome often have decreased urine output due to decreased renal perfusion. The presence of frank, bright red blood in the urine is not a typical characteristic of nephrotic syndrome but may indicate a different renal condition such as glomerulonephritis.

4. A 24-year-old female contracts hepatitis from contaminated food. During the acute (icteric) phase of the patient's illness, what would serologic testing most likely reveal?

• A. antibody to hepatitis D (anti-HDV).
• B. hepatitis B surface antigen (HBsAg).
• C. anti-hepatitis A virus immunoglobulin G (anti-HAV IgG).
• D. anti-hepatitis A virus immunoglobulin M (anti-HAV IgM).

Correct answer: D

Rationale: Hepatitis A is primarily transmitted through the oral-fecal route. During the acute phase of hepatitis A, serologic testing typically reveals anti-hepatitis A virus immunoglobulin M (anti-HAV IgM). This antibody appears early in the course of the infection. The presence of anti-HAV IgM indicates an acute infection with hepatitis A. Choices A and B are incorrect as hepatitis D and hepatitis B antigens are not typically associated with acute hepatitis A. Choice C, anti-hepatitis A virus immunoglobulin G (anti-HAV IgG), would indicate a past infection and lifelong immunity, which is not expected during the acute phase of the illness.

5. A nurse has just started her rounds delivering medication. A new patient on her rounds is a 4-year-old boy who is non-verbal. This child does not have any identification on. What should the nurse do?

• A. Contact the provider
• B. Ask the child to write their name on paper
• C. Ask a coworker about the identification of the child
• D. Ask the father who is in the room the child's name

Correct answer: D

Rationale: When encountering a non-verbal child without identification, it is appropriate for the nurse to ask the accompanying parent or guardian for the child's name. The father, being present in the room, can provide the necessary information. This ensures accurate identification to deliver the correct medication. Contacting the provider may cause unnecessary delays. Asking a non-verbal child to write their name is not feasible. Asking a coworker may not provide reliable identification as they may not have direct knowledge.

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