Nursing Elites

1. The RN is planning care at a team meeting for a 2-month-old child in bilateral leg casts for congenital clubfoot. Which of these suggestions by the PN should be considered the priority nursing goal following cast application?

• A. Infant will experience minimal pain
• B. Muscle spasms will be relieved
• C. Mobility will be managed as tolerated
• D. Tissue perfusion will be maintained

Correct answer: D

Rationale: Following cast application for congenital clubfoot in a 2-month-old child, the priority nursing goal should be to maintain tissue perfusion. This is crucial to prevent complications like compartment syndrome and ensure proper healing. While managing pain, relieving muscle spasms, and promoting mobility are important aspects of care, they are secondary to ensuring adequate tissue perfusion in this scenario.

2. Which of the following would be the best strategy for the nurse to use when teaching insulin injection techniques to a newly diagnosed client with diabetes?

• A. Provide written pre and post tests
• B. Ask questions during practice
• C. Allow another diabetic to assist
• D. Observe a return demonstration

Correct answer: D

Rationale: The best strategy for the nurse to use when teaching insulin injection techniques to a newly diagnosed client with diabetes is to observe a return demonstration. This method ensures that the client can correctly perform the technique. Providing written pre and post tests (choice A) may assess knowledge but not application. Asking questions during practice (choice B) may help with understanding but not necessarily with the actual performance. Allowing another diabetic to assist (choice C) may provide peer support but does not guarantee correct technique demonstration.

3. The nurse is caring for a 75-year-old client in congestive heart failure. Which finding suggests that digitalis levels should be reviewed?

• A. Extreme fatigue
• B. Increased appetite
• C. Intense itching
• D. Constipation

Correct answer: A

Rationale: Extreme fatigue can be a sign of digitalis toxicity, especially in older adults, and warrants a review of the client's medication levels and potential adjustment. Increased appetite, intense itching, and constipation are not typically associated with digitalis toxicity and do not directly indicate a need for a review of digitalis levels.

4. The nurse is teaching a client with cardiac disease about the anatomy and physiology of the heart. Which is the correct pathway of blood flow through the heart?

• A. Right ventricle, left ventricle, right atrium, left atrium
• B. Left ventricle, right ventricle, left atrium, right atrium
• C. Right atrium, right ventricle, left atrium, left ventricle
• D. Right atrium, left atrium, right ventricle, left ventricle

Correct answer: C

Rationale: The correct pathway of blood flow through the heart starts with blood entering the right atrium, moving to the right ventricle, then to the lungs for oxygenation, returning to the left atrium, and finally to the left ventricle before being pumped out to the body. Option A is incorrect as it starts with the ventricles instead of the atria. Option B is incorrect as it has the sequence of ventricles before atria reversed. Option D is incorrect as it has the atria and ventricles mixed up.

5. An activity designed to diagnose and treat a disease or condition in its earliest stages, before it becomes full-blown, would be classified as:

• A. primary prevention
• B. secondary prevention
• C. tertiary prevention
• D. health education

Correct answer: B

Rationale: The correct answer is B, secondary prevention. Secondary prevention focuses on early diagnosis and intervention to prevent the progression of a disease or condition. This involves detecting and treating the illness in its early stages to reduce its impact. Choice A, primary prevention, aims to prevent the development of a disease or injury before it occurs by promoting healthy behaviors. Choice C, tertiary prevention, involves managing and improving the quality of life of individuals with established conditions to prevent complications and further deterioration. Choice D, health education, refers to providing information and promoting awareness about health issues to enable individuals to make informed decisions and adopt healthy behaviors.

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