Nursing Elites

1. The nurse is assigned to care for a child who is scheduled for an appendectomy. Select the prescriptions that the nurse anticipates will be prescribed. Select one that doesn't apply.

• A. Initiate an IV line.
• B. Maintain an NPO status.
• C. Administer a Fleet enema.
• D. Administer intravenous antibiotics.

Correct answer: C

Rationale: For a child scheduled for an appendectomy, the administration of a Fleet enema is not typically required. An IV line is often initiated for fluid and medication administration, maintaining NPO status is necessary to prevent aspiration during surgery, and administering intravenous antibiotics may be part of the preoperative regimen. Therefore, the correct choice that does not apply in this case is administering a Fleet enema.

2. Which of the following is NOT a warning sign that compensatory mechanisms in a patient in shock are failing?

• A. Increasing heart rate above normal for the patient's age.
• B. Absent peripheral pulses
• C. Decreasing level of consciousness
• D. Increasing blood pressure

Correct answer: D

Rationale: In a patient in shock, increasing blood pressure is not a sign that compensatory mechanisms are failing. As shock progresses and compensatory mechanisms fail, systolic blood pressure will decrease, leading to hypotension, which is a late and ominous sign in these patients. Therefore, choices A, B, and C are warning signs of failing compensatory mechanisms in shock: an increasing heart rate above normal, absent peripheral pulses, and decreasing level of consciousness, respectively. An increasing blood pressure is not indicative of compensatory failure in shock; instead, it may be a sign of compensatory mechanisms still trying to maintain perfusion pressure.

3. 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.

4. The clinic nurse reviews the record of an infant and notes that the primary health care provider (PHCP) has documented a diagnosis of suspected Hirschsprung's disease. The nurse reviews the assessment findings documented in the record, knowing that which sign most likely led the mother to seek health care for the infant?

• A. Diarrhea
• B. Projectile vomiting
• C. Regurgitation of feedings
• D. Constipation

Correct answer: C

Rationale: Hirschsprung's disease, also known as congenital aganglionosis or aganglionic megacolon, is characterized by the absence of ganglion cells in the rectum and other parts of the affected intestine. Clinical manifestations of Hirschsprung's disease include chronic constipation with pellet-like or ribbon-like foul-smelling stools, delayed or absent passage of meconium in the neonatal period, bowel obstruction (especially in the neonatal period), abdominal pain and distention, and failure to thrive. In the case of an infant with suspected Hirschsprung's disease, regurgitation of feedings is a sign that may have led the mother to seek healthcare. This symptom can be associated with the bowel dysfunction and obstruction seen in Hirschsprung's disease. Options A, B, and D are not typically associated with Hirschsprung's disease. Diarrhea is not a common symptom, projectile vomiting is not a typical presentation, and constipation, while a symptom of the disease, is not the sign that would most likely prompt a visit to seek healthcare in an infant suspected of having Hirschsprung's disease.

5. A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). The nurse knows that a PTCA is:

• A. Surgical repair of a diseased coronary artery
• B. Placement of an automatic internal cardiac defibrillator
• C. Procedure that compresses plaque against the wall of the diseased coronary artery to improve blood flow
• D. Non-invasive radiographic examination of the heart

Correct answer: C

Rationale: Percutaneous transluminal coronary angioplasty (PTCA) is a procedure that compresses plaque against the wall of the diseased coronary artery to improve blood flow. It is performed during a cardiac catheterization to improve coronary artery blood flow in a diseased artery. Surgical repair of a diseased coronary artery is typically done through procedures like aorto-coronary bypass graft (ACBG) rather than PTCA. Placement of an automatic internal cardiac defibrillator (AICD) is a different procedure used for managing cardiac arrhythmias. Non-invasive radiographic examination of the heart refers to procedures like echocardiography or cardiac MRI, not PTCA.

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