Nursing Elites

1. The nurse instructs the mother of a child with a ventricular septal defect that she can expect the child to become cyanotic when the child does what?

• A. Experiences an elevation in temperature.
• B. Sleeps on the left side.
• C. Cries vigorously.
• D. Eats.

Correct answer: C

Rationale: The correct answer is C: Cries vigorously. When the child cries vigorously, it increases the pressure in the right ventricle, allowing unoxygenated blood to enter the circulating volume, leading to cyanosis. This occurs due to the shunting of blood from the right side of the heart to the left side through the ventricular septal defect. Choices A, B, and D are incorrect because they do not directly impact the pressure in the right ventricle, which is crucial in causing cyanosis in this scenario.

2. A healthcare worker with no known exposure to tuberculosis has received a Mantoux tuberculosis skin test. The nurse's assessment of the test after 62 hours indicates 5mm of erythema without induration. Which is the best initial nursing action?

• A. Review the healthcare worker's history for possible exposure to TB.
• B. Instruct the healthcare worker to return for a repeat test in 1 week.
• C. Refer the healthcare worker to a healthcare provider for isoniazid (INH) therapy.
• D. Document negative results in the healthcare worker's medical record.

Correct answer: D

Rationale: A Mantoux tuberculosis skin test without induration is considered negative. In this case, with 5mm of erythema and no induration, the result is negative, indicating no current infection. The best initial nursing action is to document these negative results in the healthcare worker's medical record. Reviewing the history for possible exposure to TB is unnecessary as the test result is negative. Instructing the healthcare worker to return for a repeat test or referring for INH therapy is not warranted when the test is negative.

3. A client is receiving a continuous infusion of normal saline at 125 ml/hour post abdominal surgery. The client is drowsy and complaining of constant abdominal pain and a headache. Urine output is 800 ml over the past 24h with a central venous pressure of 15 mmHg. The nurse notes respiratory crackle and bounding central pulses. Vital signs: temperature 101.2°F, Heart rate 96 beats/min, Respirations 24 breaths/min, and Blood pressure 160/90 mmHg. Which interventions should the nurse implement first?

• A. Review the last administration of IV pain medication.
• B. Administer a PRN dose of acetaminophen.
• C. Decrease IV fluids to keep the vein open (KVO) rate.
• D. Calculate total intake and output.

Correct answer: C

Rationale: The correct answer is to decrease IV fluids to the keep vein open (KVO) rate. The client is showing signs of fluid volume excess, such as drowsiness, headache, elevated CVP, crackles, bounding pulses, and increased blood pressure. Decreasing the IV fluids will help prevent further fluid overload. Reviewing the last administration of IV pain medication (Choice A) may be necessary but addressing the fluid balance issue is the priority. Administering a PRN dose of acetaminophen (Choice B) may help with the headache but does not address the underlying fluid overload. Calculating total intake and output (Choice D) is important but does not directly address the immediate issue of fluid overload and its associated symptoms.

4. A male client with diabetes mellitus is transferred from the hospital to a rehabilitation facility following treatment for a stroke resulting in right hemiplegia. He tells the nurse that his feet are always uncomfortably cool at night, preventing him from falling asleep. Which action should the nurse implement?

• A. Provide a warming pad for his feet
• B. Medicate the client with a prescribed sedative.
• C. Use a bed cradle to keep the covers off his feet.
• D. Place warm blankets next to the client's feet.

Correct answer: D

Rationale: Placing warm blankets next to the client's feet is the most appropriate action to provide warmth and comfort. This method is safe and effective in addressing the client's complaint of uncomfortably cool feet at night. Providing a warming pad (Choice A) may pose a risk of burns or injury, especially for a client with decreased sensation due to diabetes. Mediating the client with a sedative (Choice B) does not address the underlying issue of cool feet and may not be necessary. Using a bed cradle (Choice C) to hold the covers off the feet does not directly address the client's need for warmth and comfort.

5. The nurse explains to the parents of a child with developmental hip dysplasia that the application of a Pavlik harness is necessary. In what position will the harness hold the child's femurs?

• A. Abduction
• B. Adduction
• C. Flexion
• D. Extension

Correct answer: A

Rationale: The correct answer is A: Abduction. The use of the Pavlik harness is to maintain the hips in abduction for 4 to 6 months to treat developmental hip dysplasia. This position helps in stabilizing the hip joint and promoting proper growth and development. Choices B, C, and D are incorrect because the Pavlik harness specifically aims to hold the child's femurs in abduction, not adduction, flexion, or extension.

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