Nursing Elites

1. Which intervention will the nurse include in the plan of care for a patient diagnosed with a lung abscess?

• A. Teach the patient to avoid using over-the-counter expectorants.
• B. Assist the patient with chest physiotherapy and postural drainage.
• C. Notify the healthcare provider immediately regarding any bloody or foul-smelling sputum.
• D. Teach about the necessity of prolonged antibiotic therapy after discharge from the hospital.

Correct answer: D

Rationale: For a patient diagnosed with a lung abscess, the priority intervention is to educate them about the importance of prolonged antibiotic therapy post-hospital discharge. Long-term antibiotic treatment is crucial for eradicating the infecting organisms in a lung abscess. Chest physiotherapy and postural drainage are not recommended for lung abscess as they can potentially spread the infection. While foul-smelling and bloody sputum are common in lung abscess, immediate notification to the healthcare provider is essential. Avoiding the use of over-the-counter expectorants is not necessary, as expectorants can be used to facilitate coughing and clearing of secretions in this condition.

2. A patient asks the nurse whether he is a good candidate to use a CPAP machine. The nurse reviews the client's history. Which condition would contraindicate the use of a CPAP machine?

• A. The patient is in the late stage of dementia.
• B. The patient has a history of bronchitis.
• C. The patient has had suicidal gestures/attempts in the past.
• D. The patient is on beta-blockers.

Correct answer: A

Rationale: The correct answer is that the patient is in the late stage of dementia. In late-stage dementia, individuals may have an inability to follow commands and understand instructions independently, which are essential for proper installation and use of a CPAP machine. This makes using a CPAP machine challenging and potentially ineffective for patients in this condition. Choice B, having a history of bronchitis, does not contraindicate the use of a CPAP machine. In fact, CPAP therapy can be beneficial for patients with respiratory conditions like bronchitis. Choice C, a history of suicidal gestures/attempts, while concerning for the patient's mental health, does not directly contraindicate the use of a CPAP machine. Choice D, being on beta-blockers, is not a contraindication for CPAP machine use. Beta-blockers are commonly used medications for various conditions and do not interfere with the use of a CPAP machine.

3. The nurse is caring for a newborn with a suspected diagnosis of imperforate anus. The nurse monitors the infant, knowing that which is a clinical manifestation associated with this disorder?

• A. Bile-stained fecal emesis
• B. The passage of currant jelly-like stools
• C. Failure to pass meconium stool in the first 24 hours after birth
• D. Sausage-shaped mass palpated in the upper right abdominal quadrant

Correct answer: C

Rationale: Imperforate anus is the incomplete development or absence of the anus in its normal position in the perineum. Failure to pass meconium stool within the first 24 hours after birth is a key clinical manifestation associated with this disorder. This finding should prompt further assessment to confirm the suspected diagnosis. Other assessment findings in imperforate anus may include absence or stenosis of the anal rectal canal, presence of an anal membrane, and an external fistula to the perineum. Options A, B, and D describe findings typically noted in intussusception, a different condition characterized by bowel obstruction and telescoping of the intestines that can present with bile-stained fecal emesis, the passage of currant jelly-like stools, and a sausage-shaped mass palpated in the upper right abdominal quadrant.

4. While caring for a patient with respiratory disease, the nurse observes that the patient's SpO2 drops from 93% to 88% while the patient is ambulating in the hallway. What is the priority action of the nurse?

• A. Notify the healthcare provider
• B. Document the response to exercise
• C. Administer the PRN supplemental O2
• D. Encourage the patient to pace activity

Correct answer: C

Rationale: The drop in SpO2 to 88% indicates that the patient is hypoxemic and needs supplemental oxygen when exercising. Administering PRN supplemental oxygen is the priority action to correct the hypoxemia and ensure adequate oxygenation during activity. Notifying the healthcare provider can be done after stabilizing the patient's oxygen levels. Documenting the response to exercise is important but secondary to addressing the immediate hypoxemia. Encouraging the patient to pace activity is not sufficient to address the acute drop in SpO2 and provide the necessary oxygen support.

5. The infection control nurse is assigned to a patient with osteomyelitis related to a heel ulcer. The wound is 5cm in diameter and the drainage saturates the dressing so that it must be changed every hour. What is her priority intervention?

• A. Place the patient under contact precautions
• B. Use strict aseptic technique when caring for the wound
• C. Place another dressing to reinforce the first one
• D. Elevate the patient's leg to prevent more drainage

Correct answer: A

Rationale: The priority intervention for a patient with osteomyelitis related to a heel ulcer, with a wound that saturates the dressing every hour, is to place the patient under contact precautions. Contact precautions are essential when managing infectious wounds to prevent the spread of infection to healthcare workers, other patients, and visitors. Strict aseptic technique (Choice B) should always be used with wound care but is secondary to implementing contact precautions in this scenario. Placing another dressing (Choice C) or elevating the patient's leg (Choice D) may be necessary but do not address the immediate need for infection control measures.

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