Nursing Elites

1. What kind of preventive measures is MOST likely to be used to prevent Mary Eden from falling due to her muscular frailty?

• A. Physical therapy for muscle strengthening exercises
• B. Physical therapy for range of motion exercises
• C. Occupational therapy to help her with confusion
• D. Medications to help her sleep more

Correct answer: A

Rationale: Mary Eden, due to her muscular frailty, is at risk of falling. The most effective preventive measure in this case would be physical therapy focusing on muscle strengthening exercises. Strengthening exercises can help improve her muscle tone and stability, reducing the risk of falls. While range of motion exercises may be beneficial, they may not directly address her muscular frailty and stability concerns as effectively as muscle strengthening exercises. Occupational therapy aims to help individuals with activities of daily living and functional tasks, not confusion. Medications to induce more sleep can actually increase the risk of falls due to potential side effects like dizziness or disorientation, rather than preventing falls.

2. A nurse is caring for a 3-day old infant who needs an exchange transfusion. Which of the following statements is appropriate for teaching the child's parents about this procedure?

• A. The registered nurse will be performing the procedure
• B. The procedure takes approximately 1 ? hours.
• C. The nurse will draw out 250cc of blood and then immediately replace it with 250cc
• D. The infant will continue to receive phototherapy during the procedure.

Correct answer: B

Rationale: : An exchange transfusion is a method of controlling high bilirubin levels in infants when traditional phototherapy is unsuccessful. During an exchange transfusion, the physician removes 5-10 cc of blood and then replaces it with donor blood. The parents of this infant should know that the procedure is always performed by a physician and will take approximately 1 ½ hours to complete.

3. Which method is most appropriate for managing moral distress in the workplace?

• A. Recognizing that life is unfair and nurses cannot meet every need of every client
• B. Declining to act when clients or visitors make requests that are not justifiable
• C. Developing a new policy that would address the problematic situation
• D. Both A and B

Correct answer: C

Rationale: Moral distress involves negative feelings or frustration toward situations that are deemed unfair, unethical, or that cause the nurse to feel helpless in their work. It can lead to nurse burnout when ongoing issues are not resolved. The most appropriate method for managing moral distress is to develop new policies that address the problematic situations. By creating policies, nurses can work towards changing current standards and reducing the number of situations that lead to moral distress. Choices A and B are incorrect because recognizing life's unfairness and not taking action on unjustifiable requests do not actively address the root causes of moral distress or work towards resolving the issues.

4. Mr. Y had surgery two days ago and is recovering on the surgical unit of the hospital. Just before lunch, he develops chest pain and difficulties with breathing. His respiratory rate is 32/minute, his temperature is 100.8°F, and he has rales on auscultation. Which of the following nursing interventions is most appropriate in this situation?

• A. Place the client in the Trendelenburg position
• B. Contact the physician for an order for antibiotics
• C. Administer oxygen therapy
• D. Decrease his IV rate

Correct answer: C

Rationale: Chest pain, dyspnea, tachypnea, mild fever, and rales or crackles on auscultation in a client who had surgery 2 days ago may be indicative of a pulmonary embolism. The nurse should administer oxygen to address his breathing and assist him to a comfortable position to facilitate better oxygenation before contacting the physician. Placing the client in the Trendelenburg position is not recommended in this situation as it may worsen a potential pulmonary embolism by increasing venous return. Contacting the physician for antibiotics is not the priority as the immediate concern is addressing the breathing difficulty. Decreasing the IV rate is not indicated in this situation where the client is experiencing respiratory distress and needs oxygen therapy.

5. An infant is brought to the clinic by his mother, who has noticed that he holds his head in an unusual position and always faces to one side. Which of the following is the most likely explanation?

• A. Torticollis, with shortening of the sternocleidomastoid muscle
• B. Craniosynostosis, with premature closure of the cranial sutures
• C. Plagiocephaly, with flattening of one side of the head
• D. Hydrocephalus, with increased head size

Correct answer: A

Rationale: The correct answer is torticollis, characterized by the shortening of the sternocleidomastoid muscle, limiting the range of motion of the neck and causing the chin to point to the opposing side. Craniosynostosis is the premature closure of cranial sutures, leading to an abnormal head shape but not necessarily affecting head position. Plagiocephaly is flattening of one side of the head due to external forces or positioning, not muscle shortening. Hydrocephalus presents with an increased head size due to the accumulation of cerebrospinal fluid, not with a fixed head position.

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