Nursing Elites

1. The nurse is planning care for a client during the acute phase of a sickle cell vasoocclusive crisis. Which of the following actions would be most appropriate?

• A. Fluid restriction to 1000cc per day
• B. Ambulate in the hallway 4 times a day
• C. Administer analgesic therapy as ordered
• D. Encourage increased caloric intake

Correct answer: C

Rationale: Administering analgesic therapy as ordered is the most appropriate action during the acute phase of a sickle cell vasoocclusive crisis. In this phase, the primary focus is on managing the severe pain experienced by the individual. Analgesic therapy helps alleviate the pain and discomfort associated with the crisis. The other options are not the priority during this phase. Fluid restriction is not recommended as hydration is crucial in managing a vasoocclusive crisis. Ambulation may worsen the pain and should be minimized during this phase. Encouraging increased caloric intake is not directly related to managing the acute phase of a vasoocclusive crisis.

2. The nurse completes discharge teaching for a patient who has had a lung transplant. The nurse evaluates that the teaching has been effective if the patient makes which statement?

• A. I will make an appointment to see the doctor every year.
• B. I will stop taking the prednisone if I experience a dry cough.
• C. I will not worry if I feel a little short of breath with exercise.
• D. I will call the health care provider right away if I develop a fever.

Correct answer: D

Rationale: The correct answer is, 'I will call the health care provider right away if I develop a fever.' It is crucial for patients who have undergone a lung transplant to be vigilant about any signs of infection or rejection. A low-grade fever can be an early indicator of such complications, requiring immediate medical attention. While annual follow-up visits are necessary, they are not sufficient for monitoring acute changes in health post-transplant. Stopping prednisone abruptly can lead to rejection and should only be done under healthcare provider guidance. Feeling short of breath with exercise should be reported as it can indicate potential issues. Recognizing and addressing symptoms promptly is key to successful post-transplant care, and in this case, calling the healthcare provider immediately for a fever is the most appropriate action.

3. A client is found unresponsive in his room by a nurse. The client is not breathing and does not have a pulse. After calling for help, what is the next action the nurse should take?

• A. Administer 2 ventilations
• B. Perform a head-tilt, chin lift to open the airway
• C. Begin chest compressions
• D. Perform a jaw thrust to open the airway

Correct answer: C

Rationale: After finding an unresponsive client who is not breathing and has no pulse, the nurse's immediate action should be to call for help and start chest compressions. Chest compressions should be initiated at a rate of at least 100 per minute and a depth of at least 2 inches. Choice A, administering ventilations, is not the initial step as compressions take priority. Choice B, performing a head-tilt, chin lift, is also not the first step; chest compressions are crucial before airway management. Choice D, performing a jaw thrust, is typically used in cases of suspected cervical spine injury and is not the immediate action in this scenario.

4. 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.

5. The nurse has been assigned to care for a neonate just delivered who has gastroschisis. Which concern should the nurse address in the client's plan of care?

• A. Infection.
• B. Poor body image.
• C. Decreased urinary elimination.
• D. Cracking oral mucous membranes.

Correct answer: A

Rationale: In a neonate with gastroschisis, the bowel herniates through a defect in the abdominal wall without a covering membrane, which puts the neonate at high risk of infection. Immediate surgical repair is necessary due to the vulnerability of the exposed bowel to infection. Therefore, the most critical concern for the nurse to address in the plan of care of a neonate with gastroschisis is preventing infection. Poor body image is not a priority in neonatal care as neonates do not have body image concerns. Decreased urinary elimination is not typically a direct consequence of gastroschisis as it primarily affects the gastrointestinal system, not the genitourinary system. Cracking oral mucous membranes are not relevant to gastroschisis as it involves the lower gastrointestinal system, not the oral cavity.

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