Nursing Elites

1. The nurse is planning discharge instructions for the mother of a child following orchiopexy, which was performed on an outpatient basis. Which is a priority in the plan of care?

• A. Wound care
• B. Pain control measures
• C. Measurement of intake
• D. Cold and heat applications

Correct answer: A

Rationale: Following orchiopexy, the priority in the plan of care for the child's mother is wound care. The most common complications associated with orchiopexy are bleeding and infection. Discharge instructions should focus on demonstrating wound cleansing and dressing, and teaching parents to recognize signs of infection like redness, warmth, swelling, or discharge. It is crucial to prevent movement of the testicles and avoid contamination of the suture line. While analgesics may be prescribed, pain control measures are not the priority among the options presented. Measurement of intake is not essential as the child is likely to resume normal eating habits. Cold and heat applications are not typical prescribed treatments for post-orchiopexy care.

2. Administration of hepatitis B vaccine to a healthy 18-year-old patient has been effective when a specimen of the patient's blood reveals

• A. HBsAg.
• B. anti-HBs
• C. anti-HBc IgG
• D. anti-HBc IgM.

Correct answer: B

Rationale: The correct answer is 'anti-HBs'. The presence of surface antibody to HBV (anti-HBs) indicates a successful response to the hepatitis B vaccine. Anti-HBs is a marker of immunity and protection against hepatitis B infection. Choices A, C, and D are incorrect because: A) HBsAg indicates current infection with hepatitis B virus, C) anti-HBc IgG suggests past infection or immunity, and D) anti-HBc IgM is a marker of acute hepatitis B infection.

3. A 30-year-old woman is experiencing anaphylaxis from a bee sting. Emergency personnel have been called. The nurse notes the woman is breathing but short of breath. Which of the following interventions should the nurse do first?

• A. Initiate cardiopulmonary resuscitation
• B. Check for a pulse
• C. Ask the woman if she carries an emergency medical kit
• D. Stay with the woman until help comes

Correct answer: C

Rationale: In a situation where a patient is experiencing anaphylaxis, it is crucial to act swiftly. Asking the woman if she carries an emergency medical kit is the most appropriate initial intervention. Many individuals with a history of anaphylaxis carry epinephrine auto-injectors, such as epi-pens, which can be life-saving in such situations. Initiating cardiopulmonary resuscitation (CPR) is not indicated as the patient is breathing but short of breath, and CPR is not the first-line intervention for anaphylaxis. Checking for a pulse, though important, is not the initial priority in managing anaphylaxis. Staying with the woman until help arrives is essential for providing support and monitoring her condition, but confirming the availability of an emergency medical kit takes precedence to promptly address the anaphylactic reaction.

4. A patient has acute bronchitis with a nonproductive cough and wheezes. Which topic should the nurse plan to include in the teaching plan?

• A. Purpose of antibiotic therapy
• B. Ways to limit oral fluid intake
• C. Appropriate use of cough suppressants
• D. Safety concerns with home oxygen therapy

Correct answer: C

Rationale: In acute bronchitis, which is often viral, cough suppressants can help manage the symptoms of a nonproductive cough. Antibiotics are not typically used in acute bronchitis unless there are systemic symptoms indicating a bacterial infection. Limiting oral fluid intake is not recommended; in fact, maintaining adequate hydration is important. Safety concerns with home oxygen therapy may not be directly relevant to the management of acute bronchitis.

5. The child with hemolytic-uremic syndrome is anuric and will undergo peritoneal dialysis. Which measure should the nurse implement?

• A. Restrict fluids as prescribed.
• B. Care for the arteriovenous fistula.
• C. Encourage foods high in potassium.
• D. Administer analgesics as prescribed.

Correct answer: A

Rationale: In hemolytic-uremic syndrome, often associated with bacterial toxins and viruses, acute kidney injury occurs in children, leading to symptoms like anemia, thrombocytopenia, renal injury, and CNS symptoms. For an anuric child with hemolytic-uremic syndrome undergoing peritoneal dialysis, fluid restriction is vital to prevent fluid overload. Pain management is not directly related to hemolytic-uremic syndrome. Foods high in potassium should be limited, not encouraged, due to impaired kidney function. Peritoneal dialysis does not involve an arteriovenous fistula, which is specific to hemodialysis.

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