Nursing Elites

1. The nurse is caring for a postpartum client who is exhibiting symptoms of a spinal headache 24 hours following the delivery of a normal newborn. Prior to the anesthesiologist's arrival on the unit, which action should the nurse perform?

• A. Apply an abdominal binder.
• B. Cleanse the spinal injection site.
• C. Insert an indwelling Foley catheter.
• D. Place procedure equipment at the bedside.

Correct answer: A

Rationale: In a postpartum client exhibiting symptoms of a spinal headache, applying an abdominal binder is a priority action. The abdominal binder can help reduce the severity of a spinal headache by increasing intra-abdominal pressure, which may relieve pressure on the dural sac and alleviate symptoms. This intervention can be performed promptly by the nurse to provide immediate relief while waiting for further evaluation and management by the anesthesiologist. Cleansing the spinal injection site (Choice B) is not the priority in this situation as the headache is likely due to a dural puncture during epidural anesthesia rather than infection. Inserting an indwelling Foley catheter (Choice C) and placing procedure equipment at the bedside (Choice D) are not the appropriate actions to address a spinal headache and should not take precedence over applying an abdominal binder.

2. In assessing a 9-year-old boy admitted to the hospital with possible acute post-streptococcal glomerulonephritis (APSGN), what information is most significant to obtain in his history?

• A. Back pain for a few days
• B. A history of hypertension
• C. A sore throat last week
• D. Diuresis during the nights

Correct answer: C

Rationale: A recent sore throat is most significant in this case as it could indicate a preceding streptococcal infection, which is a crucial factor in diagnosing APSGN. Streptococcal infection often precedes APSGN, and recognizing this history is essential for appropriate management and treatment. Choices A, B, and D are less relevant in the context of APSGN. Back pain and diuresis are symptoms that may not directly correlate with APSGN, while a history of hypertension, although important in general health assessment, is not as specific to the current scenario compared to a recent sore throat.

3. In which chromosome pattern is Duchenne disease inherited?

• A. Autosomal dominant
• B. Autosomal recessive
• C. X-linked recessive
• D. Mitochondrial

Correct answer: C

Rationale: Duchenne disease is caused by a mutation in the DMD gene located on the X chromosome, leading to an X-linked recessive inheritance pattern. Males are typically affected by this disorder as they have only one X chromosome, while females are carriers with one normal and one affected X chromosome.

4. A male infant with a 2-day history of fever and diarrhea is brought to the clinic by his mother, who tells the nurse that the child refuses to drink anything. The nurse determines that the child has a weak cry with no tears. Which intervention is most important to implement?

• A. Provide a bottle of electrolyte solution.
• B. Infuse normal saline intravenously.
• C. Administer an antipyretic rectally.
• D. Apply an external cooling blanket.

Correct answer: B

Rationale: Infusing normal saline intravenously is crucial to treat dehydration caused by fever and diarrhea. In this scenario, the infant's weak cry with no tears indicates severe dehydration, necessitating rapid fluid replacement via intravenous normal saline to restore fluid balance and prevent complications.

5. A 16-year-old gravida 1, para 0 client has just been admitted to the hospital with a diagnosis of eclampsia. She is not presently convulsing. Which intervention should the nurse plan to include in this client’s nursing care plan?

• A. Keep airway equipment at the bedside.
• B. Allow liberal family visitation.
• C. Monitor blood pressure, pulse, and respirations q4h.
• D. Assess temperature q1h.

Correct answer: A

Rationale: In a client with eclampsia, the priority intervention is to keep airway equipment at the bedside to manage potential convulsions effectively. This proactive measure is essential to ensure rapid response and intervention in case of convulsions, which can occur in clients with eclampsia.

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