Nursing Elites

1. Which interventions should the nurse include when creating a care plan for a child with hepatitis? Select one that doesn't apply.

• A. Providing a low-fat, well-balanced diet.
• B. Teaching the child effective hand-washing techniques.
• C. Notifying the primary health care provider (PHCP) if jaundice is present.
• D. Instructing the parents to avoid administering medications unless prescribed.

Correct answer: D

Rationale: The correct answer is instructing the parents to avoid administering medications unless prescribed. This choice is not directly related to the care of a child with hepatitis. It is essential for the nurse to educate the child and family about providing a low-fat, well-balanced diet to support the liver, teaching effective hand-washing techniques to prevent the spread of infection, and notifying the primary health care provider if jaundice is present to monitor the progression of the disease and adjust the treatment plan accordingly. Avoiding unnecessary medications is crucial, but it should be done under healthcare provider guidance, so the statement should be revised to reflect this aspect. Therefore, the other options are appropriate for the care of a child with hepatitis.

2. The nursing care plan for a toddler diagnosed with Kawasaki Disease (mucocutaneous lymph node syndrome) should be based on the high risk for development of which problem?

• A. Chronic vessel plaque formation
• B. Pulmonary embolism
• C. Occlusions at the vessel bifurcations
• D. Coronary artery aneurysms

Correct answer: A

Rationale: The correct answer is chronic vessel plaque formation. Kawasaki Disease affects small and medium-sized blood vessels, leading to progressive inflammation and potential damage to the walls of medium-sized muscular arteries, which can result in coronary artery aneurysms. While other complications such as pulmonary embolism and occlusions at vessel bifurcations can occur in different conditions, for Kawasaki Disease, the primary concern is the development of chronic vessel plaque formation.

3. A 38-year-old patient with cirrhosis has ascites and 4+ edema of the feet and legs. Which nursing action will be included in the plan of care?

• A. Restrict daily dietary protein intake.
• B. Reposition the patient every 4 hours.
• C. Place the patient on a pressure-relieving mattress.
• D. Perform passive range of motion daily.

Correct answer: C

Rationale: Placing the patient on a pressure-relieving mattress is crucial to decrease the risk of skin breakdown, especially with significant edema and ascites. Adequate dietary protein intake is essential in patients with ascites to improve oncotic pressure and prevent malnutrition. Repositioning the patient every 4 hours alone may not be sufficient to prevent skin breakdown, especially in areas prone to pressure ulcers. Performing passive range of motion exercises is important for maintaining joint mobility but does not directly address the risk of skin breakdown associated with prolonged pressure on vulnerable areas.

4. Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which assessment data best supports this diagnosis?

• A. Weak, nonproductive cough effort
• B. Large amounts of greenish sputum
• C. Respiratory rate of 28 breaths/minute
• D. Resting pulse oximetry (SpO2) of 85%

Correct answer: A

Rationale: The correct answer is 'Weak, nonproductive cough effort.' A weak, nonproductive cough indicates that the patient is unable to clear the airway effectively, supporting the nursing diagnosis of ineffective airway clearance. In pneumonia, secretions can obstruct the airway, leading to ineffective clearance. Choices B, C, and D do not directly reflect ineffective airway clearance. Large amounts of greenish sputum (Choice B) may suggest infection or inflammation but do not specifically indicate ineffective airway clearance. The respiratory rate of 28 breaths/minute (Choice C) and a resting pulse oximetry (SpO2) of 85% (Choice D) are more indicative of impaired gas exchange or respiratory distress rather than ineffective airway clearance.

5. A client comes to the clinic for treatment of recurrent pelvic inflammatory disease. The nurse recognizes that this condition most frequently follows which type of infection?

• A. Trichomoniasis
• B. Chlamydia
• C. Staphylococcus
• D. Streptococcus

Correct answer: B

Rationale: Chlamydial infections are one of the most common causes of salpingitis or pelvic inflammatory disease. Chlamydia can ascend from the vagina or cervix to the reproductive organs, leading to inflammation and infection. Trichomoniasis, caused by a parasite, typically presents with different symptoms than pelvic inflammatory disease and is not the primary cause. Staphylococcus and Streptococcus are bacteria that can cause other types of infections but are not the primary culprits in most cases of pelvic inflammatory disease.

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