Nursing Elites

1. The nurse is caring for a newborn infant after surgical intervention for imperforate anus. The nurse should place the infant in which position in the postoperative period?

• A. Supine with no head elevation
• B. Side-lying with the legs flexed
• C. Side-lying with the legs extended
• D. Supine with the head elevated 30 degrees

Correct answer: B

Rationale: After surgical intervention for imperforate anus, the infant should be placed in a side-lying position with the legs flexed. This position helps reduce edema and pressure on the surgical site, preventing strain and promoting comfort. Placing the infant supine with no head elevation (Choice A) doesn't offer adequate support and may increase pressure on the area. Side-lying with the legs extended (Choice C) doesn't help reduce edema and pressure effectively. Placing the infant supine with the head elevated 30 degrees (Choice D) isn't recommended as it may not provide adequate support and comfort needed for recovery.

2. A client is brought into the emergency department after finishing a course of antibiotics for a urinary tract infection. The client is experiencing dyspnea, chest tightness, and agitation. Her blood pressure is 88/58, she has generalized hives over her body, and her lips and tongue are swollen. After the nurse calls for help, what is the next appropriate action?

• A. Start an IV and administer a 1-liter bolus of Lactated Ringer's solution
• B. Administer 0.3 mg of 1:1000 epinephrine IM
• C. Administer 15 mg diphenhydramine IM
• D. Monitor the client until help arrives

Correct answer: B

Rationale: A client experiencing an anaphylactic reaction will likely present with rash or hives, swelling of the lips, face, or tongue, hypotension, or dyspnea. In this scenario, the client is showing signs of anaphylaxis with dyspnea, chest tightness, hives, hypotension, and swelling of the lips and tongue. The next appropriate action would be to administer 0.3 mg of 1:1000 epinephrine intramuscularly. Epinephrine helps relax the muscles of the airway, improve breathing, and increase oxygenation, which is crucial in managing anaphylaxis. Starting an IV and administering fluids can be important but not the immediate priority. Diphenhydramine may be used as an adjunct therapy but should not delay the administration of epinephrine in the acute phase of anaphylaxis. Monitoring the client without providing immediate treatment can lead to a worsening of the anaphylactic reaction, potentially resulting in a life-threatening situation.

3. The pediatric nurse caring for a 3-year-old child with cerebral palsy (CP) prepares a home care teaching plan for the caregivers on discharge. Which items will the nurse include in the teaching plan? (Select one that does not apply.)

• A. Apply splints and braces to facilitate muscle control.
• B. Buy toys that are appropriate for the child's abilities.
• C. Encourage the child to perform self-care tasks.
• D. Use skeletal muscle relaxants for short-term control.

Correct answer: D

Rationale: When developing a discharge teaching plan for a child with cerebral palsy (CP), the nurse should focus on strategies to enhance the child's independence and functional abilities. Choices A, B, and C are appropriate interventions to include in the teaching plan for a child with CP. Applying splints and braces can help facilitate muscle control and improve body functioning. Buying toys that are appropriate for the child's abilities can promote engagement and development. Encouraging the child to perform self-care tasks fosters independence and skill development. However, the use of skeletal muscle relaxants for short-term control is not typically a part of routine care for pediatric patients with CP. These medications are usually reserved for specific situations and are not a standard component of home care teaching plans for children with CP.

4. A patient is getting discharged from a skilled nursing facility (SNF). The patient has a history of severe COPD and PVD. The patient is primarily concerned about his ability to breathe easily. Which of the following would be the best instruction for this patient?

• A. Deep breathing techniques to increase oxygen levels.
• B. Cough regularly and deeply to clear airway passages.
• C. Cough following bronchodilator utilization.
• D. Decrease CO2 levels by increasing oxygen intake during meals.

Correct answer: C

Rationale: The correct answer is to instruct the patient to cough following bronchodilator utilization. In COPD and PVD patients, bronchodilators help to open up the airways, making coughing more effective in clearing secretions from the lungs. This instruction can aid in improving the patient's ability to breathe by enhancing airway clearance. Deep breathing techniques (Choice A) may help increase oxygen levels but may not directly address the patient's immediate concern of breathing difficulty. Coughing regularly and deeply (Choice B) can be beneficial, but the timing following bronchodilator use is more crucial to maximize its effectiveness. Decreasing CO2 levels by increasing oxygen intake during meals (Choice D) does not directly address the patient's concern about breathing ease or the role of bronchodilators in improving cough effectiveness.

5. The nurse is caring for a newborn with a suspected diagnosis of imperforate anus. The nurse monitors the infant, knowing that which is a clinical manifestation associated with this disorder?

• A. Bile-stained fecal emesis
• B. The passage of currant jelly-like stools
• C. Failure to pass meconium stool in the first 24 hours after birth
• D. Sausage-shaped mass palpated in the upper right abdominal quadrant

Correct answer: C

Rationale: Imperforate anus is the incomplete development or absence of the anus in its normal position in the perineum. Failure to pass meconium stool within the first 24 hours after birth is a key clinical manifestation associated with this disorder. This finding should prompt further assessment to confirm the suspected diagnosis. Other assessment findings in imperforate anus may include absence or stenosis of the anal rectal canal, presence of an anal membrane, and an external fistula to the perineum. Options A, B, and D describe findings typically noted in intussusception, a different condition characterized by bowel obstruction and telescoping of the intestines that can present with bile-stained fecal emesis, the passage of currant jelly-like stools, and a sausage-shaped mass palpated in the upper right abdominal quadrant.

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