Nursing Elites

1. Which type of Leukocyte is involved with allergic responses and the destruction of parasitic worms?

• A. Neutrophils
• B. Lymphocytes
• C. Eosinophils
• D. Monocytes

Correct answer: C

Rationale: Eosinophils are the correct answer. Eosinophils are specialized white blood cells that play a crucial role in allergic responses and combating parasitic infections. They release substances to destroy parasites and modulate allergic reactions. Neutrophils (Choice A) are mainly involved in fighting bacterial infections. Lymphocytes (Choice B) play a key role in the immune response, including antibody production, but are not primarily responsible for combating parasites or allergic responses. Monocytes (Choice D) are involved in immune defense, differentiating into macrophages or dendritic cells, but they are not mainly associated with allergic responses or parasitic worm destruction.

2. A client with skin grafts covering full-thickness burns on both arms and legs is scheduled for a dressing change. The client is nervous and requests that the dressing change be skipped this time. What action is most important for the nurse to take?

• A. Explain the importance of regular dressing changes
• B. Administer an anti-anxiety medication
• C. Proceed with the scheduled dressing change
• D. Encourage the client to express any anxieties

Correct answer: A

Rationale: In this situation, the most important action for the nurse to take is to explain the importance of regular dressing changes to the client. By doing so, the nurse can help the client understand the necessity for wound healing and infection prevention. Administering anti-anxiety medication (Choice B) may not address the root cause of the client's anxiety, which is the lack of understanding. Proceeding with the scheduled dressing change (Choice C) without addressing the client's concerns can worsen their anxiety and decrease trust. Encouraging the client to express any anxieties (Choice D) is important but not as crucial as ensuring the client comprehends the rationale behind the dressing change.

3. Two weeks following a Billroth II (gastrojejunostomy), a client develops nausea, diarrhea, and diaphoresis after every meal. When the nurse develops a teaching plan for this client, which expected outcome statement is the most relevant?

• A. Describes a schedule for antacid use in combination with other prescribed medications
• B. Selects a pattern of small meals interspersed with fluid intake
• C. Commits to engaging in a variety of stress reduction techniques
• D. Expresses a commitment to decrease nicotine intake

Correct answer: B

Rationale: The symptoms described are indicative of dumping syndrome, a common complication following a Billroth II procedure. Dumping syndrome presents with symptoms such as nausea, diarrhea, and diaphoresis after meals. To manage these symptoms effectively, the client should opt for small, frequent meals and avoid consuming fluids along with meals. Choice A is inaccurate because antacid use does not directly address the symptoms of dumping syndrome. Choice C is irrelevant as stress reduction techniques are not the primary intervention for dumping syndrome. Choice D is unrelated to the symptoms experienced by the client, making it an inappropriate choice.

4. On admission to the Emergency Department, a female client who was diagnosed with bipolar disorder 3 years ago reports that this morning she took a handful of medications and left a suicide note for her family. Which information is most important for the nurse to obtain?

• A. Which family member has the client's suicide note?
• B. When the client last took medications for bipolar disorder?
• C. What medications the client used for the suicide attempt?
• D. Whether the client has ever attempted suicide in the past?

Correct answer: C

Rationale: Identifying the specific medications taken during a suicide attempt is crucial for determining the appropriate treatment and assessing the potential toxicity or interactions. This information helps healthcare providers initiate the necessary interventions promptly. Option A is not as critical as knowing the medications used. Option B focuses on the timing of the last medication intake rather than the specific drugs taken for the overdose. Option D, while relevant, does not provide immediate actionable information compared to identifying the substances involved in the suicide attempt.

5. The nurse is caring for a client with a tracheostomy. Which action should the nurse perform when suctioning the tracheostomy tube?

• A. Increase wall suction while removing the suction catheter
• B. Instill 10 ml of sterile saline into the tracheostomy tube before applying continuous suction
• C. Suction the client’s oropharynx after tracheal suctioning
• D. Insert the suction catheter into the trachea, and apply intermittent suction with removal of the catheter

Correct answer: D

Rationale: When suctioning a tracheostomy tube, it is essential to insert the suction catheter into the trachea and apply intermittent suction with removal of the catheter. This technique helps prevent damage to the trachea and reduces discomfort for the client. Choice A is incorrect because increasing wall suction with the removal of the suction catheter can cause trauma to the tracheal mucosa. Choice B is incorrect because instilling saline into the tracheostomy tube before suctioning is not recommended as it can lead to complications. Choice C is incorrect as oropharyngeal suctioning should be done before tracheal suctioning to prevent the risk of aspiration.

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