Nursing Elites

1. The nurse is caring for a newborn with a myelomeningocele. Before surgery, what should the nursing interventions include?

• A. Leaving the lesion uncovered and placing the infant supine
• B. Covering the lesion with a sterile, saline-soaked gauze
• C. Applying lotion to the lesion to keep it moist
• D. Covering the lesion with a dry, sterile gauze

Correct answer: B

Rationale: The correct intervention before surgery for a newborn with a myelomeningocele is to cover the lesion with a sterile, saline-soaked gauze. This helps protect the exposed spinal cord and meninges from infection and damage. Choice A is incorrect because leaving the lesion uncovered can increase the risk of infection. Choice C is incorrect because applying lotion can introduce contaminants to the lesion. Choice D is incorrect because covering the lesion with a dry gauze can lead to adherence of the gauze to the wound, causing trauma upon removal and disrupting the healing process.

2. Following surgical repair of a cleft palate, what should be used to prevent injury to the suture line?

• A. Straw
• B. Spoon
• C. Syringe
• D. Cup

Correct answer: D

Rationale: Following surgical repair of a cleft palate, a cup should be used to prevent injury to the suture line. Utensils such as straws, spoons, droppers, and syringes should be avoided as they can cause trauma to the surgical site. Using a cup reduces the risk of disrupting the sutures and promotes proper healing.

3. How should the nurse measure urinary output for an infant with dehydration?

• A. Attaching a urine collecting bag
• B. Wringing out the diaper
• C. Weighing the diaper
• D. Inserting a catheter

Correct answer: C

Rationale: The correct way to measure urinary output for an infant with dehydration is by weighing the diaper. Wet diapers are weighed to assess the amount of output accurately. Attaching a urine collecting bag and inserting a catheter are invasive methods not typically used for routine measurement of urinary output in infants. Wringing out the diaper can lead to inaccurate measurements and is not a recommended method for assessing urinary output.

4. In planning care for a postoperative client with hypovolemic shock, which problem is most important to include in the plan of care?

• A. Risk for infection.
• B. Risk for falls.
• C. Impaired skin integrity.
• D. Activity intolerance.

Correct answer: B

Rationale: The correct answer is B: Risk for falls. In a postoperative client with hypovolemic shock, the most crucial problem to address is the risk for falls. Hypovolemic shock can result in dizziness and weakness, making the client prone to falling. Preventing falls is essential to avoid further injury or complications. Choices A, C, and D are not the top priority in this scenario. While infection, impaired skin integrity, and activity intolerance are important concerns, preventing falls takes precedence due to the immediate risk of injury associated with hypovolemic shock.

5. Which signs/symptoms would be considered classical signs of meningeal irritation?

• A. Positive Kernig sign, diarrhea, and headache
• B. Negative Brudzinski sign, positive Kernig sign, and irritability
• C. Positive Brudzinski sign, positive Kernig sign, and photophobia
• D. Negative Kernig sign, vomiting, and fever

Correct answer: C

Rationale: The correct answer is C: Positive Brudzinski sign, positive Kernig sign, and photophobia are considered classical signs of meningeal irritation. The Kernig sign is positive when the leg is extended at the knee and then raised, resulting in pain and resistance. The Brudzinski sign is positive when flexing the neck causes flexion of the hips and knees due to meningeal irritation. Photophobia, or sensitivity to light, is a common symptom due to meningeal inflammation. Choices A, B, and D are incorrect because they do not include the classic signs associated with meningeal irritation.

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