Nursing Elites

1. Which is a priority nursing intervention for the cognitively impaired child?

• A. The family will provide good nutrition.
• B. The family will provide loving interactions.
• C. Stimulation will improve.
• D. There will be contact with peers.

Correct answer: B

Rationale: The correct answer is B because nursing interventions for cognitively impaired children prioritize promoting loving interactions with family. This support helps in creating a nurturing environment that contributes to the child's well-being and development. Choice A is not the priority as good nutrition, though important, may not address the immediate emotional and social needs of the child. Choice C is vague and does not specify how stimulation will be provided. Choice D, contact with peers, is also valuable but not as crucial as the primary relationships and interactions within the family unit for a cognitively impaired child.

2. The nurse is caring for a client with acute pancreatitis. Which laboratory result is most indicative of this condition?

• A. Elevated serum amylase
• B. Decreased serum bilirubin
• C. Increased blood urea nitrogen (BUN)
• D. Decreased alkaline phosphatase

Correct answer: A

Rationale: Elevated serum amylase is the most indicative laboratory result of acute pancreatitis. In this condition, the pancreas becomes inflamed, leading to the leakage of amylase and lipase into the bloodstream. Elevated serum amylase levels are a classic finding in acute pancreatitis. Choices B, C, and D are not typically associated with acute pancreatitis. Decreased serum bilirubin, increased blood urea nitrogen (BUN), and decreased alkaline phosphatase levels are not specific markers for acute pancreatitis.

3. In the change of shift report, the nurse is told that a client has a stage 2 pressure ulcer. Which ulcer appearance is most likely to be observed?

• A. Shallow open ulcer with a red-pink wound bed.
• B. Intact skin with non-blanchable redness.
• C. Full-thickness tissue loss with visible fat.
• D. Full-thickness tissue loss with exposed bone, tendon, or muscle.

Correct answer: A

Rationale: The correct answer is A: 'Shallow open ulcer with a red-pink wound bed.' Stage 2 pressure ulcers involve partial-thickness skin loss and typically appear as shallow open ulcers with a red-pink wound bed. Choice B describes a stage 1 ulcer, where the skin is intact but shows non-blanchable redness. Choice C describes a stage 3 ulcer, with full-thickness tissue loss exposing fat. Choice D is characteristic of a stage 4 ulcer, where there is full-thickness tissue loss exposing bone, tendon, or muscle. Therefore, option A best fits the description of a stage 2 pressure ulcer.

4. After a CT scan with intravenous contrast medium, a client returns to the room complaining of shortness of breath and itching. Which intervention should the nurse implement?

• A. Call respiratory therapy to administer a breathing treatment.
• B. Send for an emergency tracheostomy set.
• C. Prepare a dose of epinephrine.
• D. Review the client's complete list of allergies.

Correct answer: C

Rationale: Preparing a dose of epinephrine is the correct intervention in this situation as the client is displaying symptoms of an anaphylactic reaction to the contrast medium used during the CT scan. Epinephrine is the first-line treatment for anaphylaxis due to its ability to reverse the symptoms rapidly. Calling respiratory therapy for a breathing treatment (Choice A) may not address the underlying allergic reaction and delay appropriate treatment. Sending for an emergency tracheostomy set (Choice B) is not indicated as the client's symptoms suggest an allergic reaction rather than airway obstruction. Reviewing the client's complete list of allergies (Choice D) is important but would not provide immediate relief for the client's current symptoms; administering epinephrine takes precedence in this situation.

5. In planning care for a postoperative client with hypovolemic shock, which problem is most important to include in the plan of care?

• A. Risk for infection.
• B. Risk for falls.
• C. Impaired skin integrity.
• D. Activity intolerance.

Correct answer: B

Rationale: The correct answer is B: Risk for falls. In a postoperative client with hypovolemic shock, the most crucial problem to address is the risk for falls. Hypovolemic shock can result in dizziness and weakness, making the client prone to falling. Preventing falls is essential to avoid further injury or complications. Choices A, C, and D are not the top priority in this scenario. While infection, impaired skin integrity, and activity intolerance are important concerns, preventing falls takes precedence due to the immediate risk of injury associated with hypovolemic shock.

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