Nursing Elites

1. The healthcare provider is planning care for a 3-month-old infant immediately postoperative following placement of a ventriculoperitoneal shunt for hydrocephalus. The healthcare provider needs to

• A. Assess for abdominal distention
• B. Maintain the infant in an upright position
• C. Begin feeding formula when the infant is alert
• D. Pump the shunt to assess for proper function

Correct answer: A

Rationale: Assessing for abdominal distention is crucial in this situation as it can indicate a complication with the shunt or fluid accumulation. Abdominal distention may suggest an issue with the shunt placement, such as obstruction or overdrainage, which requires immediate intervention. Maintaining the infant in an upright position (Choice B) is not the priority immediately postoperatively following a ventriculoperitoneal shunt placement. Beginning formula feedings when the infant is alert (Choice C) may be appropriate but is not the priority over assessing for abdominal distention. Pumping the shunt to assess for proper function (Choice D) is not a recommended nursing intervention postoperatively and should be done by a qualified healthcare provider.

2. A client with a chest tube following thoracic surgery needs care. Which task should the nurse delegate to an assistive personnel?

• A. Teach deep breathing and coughing to the client.
• B. Assist the client to select food choices from the menu.
• C. Evaluate the client’s response to pain medication.
• D. Monitor the characteristics of the client's chest tube drainage.

Correct answer: B

Rationale: The correct answer is B because assisting the client with food choices is a task that can be safely delegated to assistive personnel. This task does not require nursing judgment or specialized skills. Choices A, C, and D involve assessing the client's condition, response to treatment, and monitoring critical aspects of care, which are nursing responsibilities that necessitate specialized knowledge and judgment. Teaching deep breathing and coughing (A), evaluating pain medication response (C), and monitoring chest tube drainage (D) require a higher level of training and expertise that should be performed by the nurse.

3. A nurse is providing home care for a client who is receiving tube feedings and medication through a gastrostomy tube. The family member providing the feedings reports that the client has begun to have diarrhea. For which of the following practices should the nurse intervene?

• A. The family member washes out the feeding bag with warm water once every 24 hours.
• B. The family member washes out the feeding bag with hot water once every 24 hours.
• C. The family member washes out the feeding bag with soap and water every 24 hours.
• D. The family member changes the feeding bag every 24 hours.

Correct answer: A

Rationale: The correct answer is A. Washing out the feeding bag with warm water once every 24 hours is not sufficient to prevent bacterial growth and can lead to diarrhea. Using hot water may damage the feeding bag. Washing out the feeding bag with soap and water every 24 hours is excessive and may leave residue that could be harmful. Changing the feeding bag every 24 hours is important for preventing infections but does not directly address the issue of diarrhea in this case.

4. An 18-year-old client is admitted to the intensive care unit from the emergency room following a diving accident. The injury is suspected to be at the level of the 2nd cervical vertebra. The nurse's priority assessment should be

• A. Response to stimuli
• B. Bladder control
• C. Respiratory function
• D. Muscle strength

Correct answer: C

Rationale: Injuries at the level of the 2nd cervical vertebra can affect the phrenic nerve, leading to potential impairment of respiratory function. Assessing respiratory function is crucial as compromised breathing can quickly escalate to life-threatening situations. While response to stimuli is important, ensuring adequate oxygenation takes precedence due to the immediate threat to life. Bladder control may be affected by spinal cord injuries at higher levels, but it is not the priority in this scenario. Muscle strength is a potential consequence of cervical spinal cord injury, but assessing respiratory function is more critical in the acute phase.

5. When reviewing car seat use with the parents of a 1-month-old infant, which of the following instructions should the nurse include?

• A. Use a car seat that has a three-point harness system.
• B. Position the car seat so that the infant is rear-facing.
• C. Secure the car seat in the front passenger seat of the vehicle.
• D. Convert to a booster seat after 12 months.

Correct answer: B

Rationale: The correct instruction for car seat use with a 1-month-old infant is to position the car seat so that the infant is rear-facing. This orientation provides the safest option for infants as it supports their head, neck, and spine. While using a car seat with a three-point harness system is appropriate for infants, placing the car seat in the front passenger seat is not recommended due to the presence of airbags, which can pose a risk to the infant in the event of deployment. Additionally, transitioning to a booster seat is not suitable at 12 months; infants should remain in rear-facing car seats until they outgrow the seat's height or weight limits, typically around 2 years of age.

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