Nursing Elites

1. What nursing intervention is most important to implement after a client has completed a myelogram?

• A. Lie-sit-stand blood pressure measurement
• B. Abdominal assessment for distention and bowel sounds
• C. Neurovascular assessment of lower extremities
• D. Assessment of skin temperature and turgor

Correct answer: C

Rationale: The correct answer is C: Neurovascular assessment of the lower extremities. After a myelogram, it is crucial to monitor the neurovascular status to detect any signs of complications such as impaired circulation or nerve damage. This assessment helps in identifying early signs of vascular compromise or neurological deficits. Choices A, B, and D are not the priority after a myelogram. Lie-sit-stand blood pressure measurement is not directly related to post-myelogram care. Abdominal assessment and skin assessment are important but not the priority immediately after this procedure.

2. A 5-week-old infant who developed projectile vomiting over the last two weeks is diagnosed with hypertrophic pyloric stenosis. Which intervention should the nurse plan to implement?

• A. Instruct the mother to give the child sugar water only
• B. Maintain intravenous fluid therapy per prescription
• C. Provide Pedialyte feedings via the nasogastric tube
• D. Offer the infant Pedialyte feedings every 2 hours

Correct answer: B

Rationale: Maintaining intravenous fluid therapy is crucial for managing dehydration and electrolyte imbalances caused by the vomiting in hypertrophic pyloric stenosis. Instructing the mother to give sugar water only (Choice A) is not appropriate as it does not address the dehydration and electrolyte imbalances adequately. Providing Pedialyte feedings via the nasogastric tube (Choice C) may not be sufficient to manage the severe fluid and electrolyte losses caused by the condition. Offering Pedialyte feedings every 2 hours (Choice D) may not be as effective as maintaining intravenous fluid therapy, especially in cases where rapid rehydration is necessary.

3. Based on the information provided in this client’s medical record during labor, which intervention should the nurse implement?

• A. Apply oxygen at 10 L per minute via mask
• B. Stop the oxytocin infusion
• C. Turn the client to the right lateral position
• D. Continue monitoring the progress of labor

Correct answer: C

Rationale: Turning the client to the right lateral position is essential as it can improve fetal oxygenation and uterine blood flow, promoting better labor outcomes. This intervention helps relieve pressure on blood vessels, enhancing blood flow to the placenta and improving oxygen supply to the fetus. Applying oxygen at a specific rate may not address the underlying issue of compromised blood flow and oxygenation. Stopping the oxytocin infusion is not the priority unless medically indicated as it can affect labor progression. While monitoring the progress of labor is important, actively addressing the compromised fetal oxygenation and uterine blood flow by changing the client's position takes precedence in this scenario.

4. An older adult resident of a long-term care facility has a 5-year history of hypertension. The client has a headache and rates the pain 5 on a pain scale of 0 to 10. The client’s blood pressure is currently 142/89. Which interventions should the nurse implement? (Select all that apply)

• A. Administer the scheduled daily dose of lisinopril.
• B. Assess the client for postural hypotension.
• C. Notify the healthcare provider immediately.
• D. Provide a PRN dose of acetaminophen for the headache.

Correct answer: A

Rationale: In this scenario, the client's blood pressure of 142/89 is within an acceptable range for someone with a history of hypertension. The client's headache with a pain rating of 5 does not warrant an immediate notification to the healthcare provider. Administering the scheduled dose of lisinopril is appropriate to manage the client's hypertension. Assessing the client for postural hypotension is relevant due to the client's age and hypertension history. Providing a PRN dose of acetaminophen for the headache is not necessary at this point as the pain level is moderate and can be managed with other interventions.

5. The client has silvery scaling plaques bilaterally on elbows, forearms, and palms. When scratched, the skin bleeds over these plaques. What is most important to include in this client’s plan of care?

• A. Interventions to decrease emotional stress
• B. Precautions about avoiding sunlight
• C. Strategies to increase omega-3 fatty acids in the diet
• D. Instruct about applying a corticosteroid cream

Correct answer: A

Rationale: The most important aspect to include in this client's plan of care is interventions to decrease emotional stress. Psoriasis, characterized by silvery scaling plaques on the skin, can be exacerbated by emotional stress. Managing stress is crucial in controlling the condition. Precautions about avoiding sunlight are important in psoriasis management, but emotional stress has a more significant impact. While omega-3 fatty acids may provide some benefits, stress management should take priority. Applying a corticosteroid cream may help with symptoms, but addressing emotional stress is crucial for long-term management of psoriasis.

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