Nursing Elites

1. Which of the following statements best describes postural drainage as part of chest physiotherapy?

• A. Tapping on the chest wall to loosen secretions
• B. Squeezing the abdomen to increase expansion of the upper chest
• C. Using gravity to move secretions in the lung tissue
• D. Dilating the trachea to facilitate better release of secretions

Correct answer: C

Rationale: Postural drainage is a technique used in chest physiotherapy for clients with accumulated lung secretions. It involves positioning the client to utilize gravity in moving secretions from the lungs. Choice A, tapping on the chest wall, describes percussion, not postural drainage. Choice B, squeezing the abdomen, is not a correct description of postural drainage. Choice D, dilating the trachea, is not related to postural drainage but may be associated with airway clearance techniques.

2. The nurse is caring for a 10-year-old on admission to the burn unit. One assessment parameter that will indicate that the child has adequate fluid replacement is:

• A. Urinary output of 30 ml per hour
• B. No complaints of thirst
• C. Increased hematocrit
• D. Good skin turgor around burn

Correct answer: A

Rationale: For a child of this age, this is adequate output, yet does not suggest overload. Disruption of sodium-ATPase activity presumably causes an intracellular sodium shift which contributes to hypovolemia and cellular edema. Heat injury also initiates the release of inflammatory and vasoactive mediators. These mediators are responsible for local vasoconstriction, systemic vasodilation, and increased transcapillary permeability. Increase in transcapillary permeability results in a rapid transfer of water, inorganic solutes, and plasma proteins between the intravascular and interstitial spaces.

3. The nurse is providing discharge instructions to the mother of a child who had a cleft palate repair. Which statement should the nurse make to the mother?

• A. You should use an orthodontic nipple on the child's bottle.
• B. You need to use a plastic spoon to feed the child.
• C. You can allow the child to use a pacifier but only for 30 minutes at a time.
• D. You need to monitor the child's temperature for signs of infection using an oral thermometer.

Correct answer: A

Rationale: After a cleft palate repair, it is crucial to use an orthodontic nipple on the child's bottle to feed them appropriately. The mother should be instructed to give the child baby food or baby food mixed with water. It is important to avoid introducing straws, pacifiers, spoons, or fingers into the child's mouth for 7 to 10 days post-surgery to prevent complications. The use of a pacifier should be avoided for at least 2 weeks following the surgical repair to promote proper healing. Additionally, taking oral temperatures should be avoided, and alternative temperature monitoring methods should be utilized to reduce the risk of infection. Therefore, options B, C, and D are incorrect because they could potentially lead to complications or hinder the child's recovery after cleft palate repair.

4. A patient is suspected to have sustained a spinal cord injury. What best describes the overarching principles used to guide the care for this type of condition?

• A. Immobilize the cervical area to prevent further injury
• B. Monitor the patient's level of consciousness to prevent neurologic deterioration
• C. Help the patient with activities of daily living and provide emotional and physical support to help them adjust to their injury
• D. Facilitate tissue perfusion to the spinal cord while maintaining airway and breathing

Correct answer: D

Rationale: The correct answer is to facilitate tissue perfusion to the spinal cord while maintaining airway and breathing. In the acute phase of a spinal cord injury, ensuring proper tissue perfusion to the spinal cord is crucial to prevent further damage. Maintaining airway, breathing, and circulation is essential in guiding the overall care for a patient with a spinal cord injury. Choices A, B, and C, while important in certain aspects of care, are not the overarching principles that guide the immediate management of a suspected spinal cord injury.

5. To detect possible complications in a patient with severe cirrhosis who has bleeding esophageal varices, it is most important for the nurse to monitor

• A. bilirubin levels.
• B. ammonia levels.
• C. potassium levels.
• D. prothrombin time.

Correct answer: B

Rationale: In a patient with severe cirrhosis and bleeding esophageal varices, monitoring ammonia levels is crucial. Severe liver dysfunction impairs the metabolism of protein in the GI tract, leading to increased ammonia levels. Elevated ammonia levels can result in hepatic encephalopathy, a serious complication. Monitoring bilirubin levels is important for assessing liver function and jaundice but may not directly reflect the risk of complications from bleeding esophageal varices. Potassium levels are important but not the most critical in this scenario. Prothrombin time is essential for evaluating coagulation status but does not directly relate to the risk of complications from bleeding esophageal varices in this patient.

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