Nursing Elites

1. The nurse is assessing an infant with developmental dysplasia of the hip. Which finding would the nurse anticipate?

• A. Unequal leg length
• B. Limited adduction
• C. Diminished femoral pulses
• D. Symmetrical gluteal folds

Correct answer: A

Rationale: In developmental dysplasia of the hip (DDH), one of the key findings is unequal leg length. This occurs due to the dislocation of the hip joint, where the ball is loose in the socket. Limited adduction, the inability to bring the hip and knee towards the midline of the body, is also a common finding in DDH. Diminished femoral pulses are not typically associated with DDH, as it primarily affects the skeletal structure rather than vascular supply. Symmetrical gluteal folds are normal in infants and do not indicate DDH, as asymmetry in gluteal folds can be a sign of hip dislocation.

2. The nurse is caring for a patient who has recently had a successful catheter ablation. Which assessment finding demonstrates a successful outcome of this procedure?

• A. The patient is free of electrolyte imbalances
• B. The patient's WBC count is within normal limits
• C. The patient's EKG reading is regular
• D. The patient's urine output is 45 mL/hour

Correct answer: C

Rationale: A successful outcome of a catheter ablation procedure for arrhythmias, particularly SVT, is indicated by a regular EKG reading. Catheter ablation involves the use of radiofrequency energy to destroy the conduction fiber in the heart responsible for the arrhythmia. This destruction helps in preventing further episodes of arrhythmia. While choices A, B, and D are important assessments in patient care, they are not specific indicators of the success of a catheter ablation procedure. Electrolyte imbalances, WBC count, and urine output can be affected by various factors and are not directly related to the effectiveness of a catheter ablation in treating arrhythmias.

3. When caring for an asthmatic patient with an early-phase reaction, which of the following is indicative of an early-phase reaction?

• A. Rapid bronchospasms
• B. Inflammatory epithelial lesions
• C. Increased secretions
• D. Increased mucosal edema

Correct answer: A

Rationale: Rapid bronchospasms are a symptom of an early-phase reaction in an asthmatic patient. During the early phase, bronchospasms occur due to immediate hypersensitivity reactions. Inflammatory epithelial lesions, increased secretions, and increased mucosal edema are typically seen in late-phase reactions as part of the inflammatory response that occurs later. Therefore, rapid bronchospasms are most indicative of an early-phase reaction.

4. The nurse develops a plan of care to prevent aspiration in a high-risk patient. Which nursing action will be most effective?

• A. Turn and reposition immobile patients at least every 2 hours.
• B. Place patients with altered consciousness in side-lying positions.
• C. Monitor for respiratory symptoms in immunosuppressed patients.
• D. Insert nasogastric tube for feedings in patients with swallowing problems.

Correct answer: B

Rationale: To prevent aspiration in a high-risk patient, the most effective nursing action is to place patients with altered consciousness in side-lying positions. This position helps decrease the risk of aspiration as it prevents pooling of secretions and facilitates drainage. Turning and repositioning immobile patients every 2 hours is essential for preventing pressure ulcers and improving circulation but does not directly address the risk of aspiration. Monitoring respiratory symptoms in immunosuppressed patients is crucial to detect pneumonia early, but it does not directly prevent aspiration. Inserting a nasogastric tube for feedings in patients with swallowing problems may be necessary for nutritional support but does not address the risk of aspiration directly. Patients at high risk for aspiration include those with altered consciousness, difficulty swallowing, and those with nasogastric intubation, among others. Placing patients with altered consciousness in a side-lying position is a key intervention to reduce the risk of aspiration in this population. Other high-risk groups for aspiration include those who are seriously ill, have poor dentition, or are on acid-reducing medications.

5. The nurse is reviewing the lab results of a patient taking lithium for schizoaffective disorder. The lab results show that the blood lithium value is 1.7 mcg/L. What would the nurse take as the priority action?

• A. Induce vomiting
• B. Hold the next dose of Lithium
• C. Administer an antiemetic
• D. Give the next dose of Lithium

Correct answer: B

Rationale: The correct answer is to hold the next dose of Lithium. The blood lithium value of 1.7 mcg/L exceeds the therapeutic range of 0.5-1.5 mcg/L, indicating potential toxicity. Holding the next dose is crucial to prevent further accumulation of lithium in the bloodstream. Inducing vomiting is not appropriate in this situation as the priority is to prevent further absorption of lithium. Administering an antiemetic is not the priority in lithium toxicity. Giving the next dose of lithium would exacerbate the toxicity and should be avoided.

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