Nursing Elites

1. While caring for a client who was admitted with myocardial infarction (MI) 2 days ago, the nurse notes today's temperature is 101.1 degrees Fahrenheit (38.5 degrees Celsius). The appropriate nursing intervention is to

• A. Call the health care provider immediately
• B. Administer acetaminophen as ordered as this is normal at this time
• C. Send blood, urine, and sputum for culture
• D. Increase the client's fluid intake

Correct answer: B

Rationale: In this scenario, the nurse should administer acetaminophen as ordered because a slight fever is normal after an MI. This intervention can help manage the fever unless other complications are present. Calling the health care provider immediately is not necessary for a slight fever post-MI. Sending blood, urine, and sputum for culture is not indicated solely based on a slight fever without other symptoms or signs of infection. Increasing fluid intake may be beneficial for various reasons but is not the priority in this situation where managing the fever with acetaminophen is appropriate.

2. When a client is receiving external beam radiation to the mediastinum for treatment of bronchial cancer, which of the following should take priority in planning care?

• A. Esophagitis
• B. Leukopenia
• C. Fatigue
• D. Skin irritation

Correct answer: B

Rationale: Leukopenia should take priority in planning care for a client receiving external beam radiation to the mediastinum for bronchial cancer because it is a serious side effect that increases the risk of infection. Monitoring leukopenia is crucial to prevent complications. Esophagitis, fatigue, and skin irritation are also potential side effects of radiation therapy, but leukopenia poses a higher risk of life-threatening infections, requiring immediate attention.

3. A nurse is to collect a sputum specimen for acid-fast bacillus (AFB) from a client. Which action should the nurse take first?

• A. Ask the client to cough sputum into a container
• B. Have the client take several deep breaths
• C. Provide an appropriate specimen container
• D. Assist with oral hygiene

Correct answer: D

Rationale: Assisting with oral hygiene is the essential initial step before collecting a sputum specimen for acid-fast bacillus (AFB) to prevent contamination of the sample. Ensuring the client's mouth is clean reduces the risk of introducing unwanted bacteria into the specimen. Asking the client to cough sputum into a container, having the client take deep breaths, and providing a specimen container are important steps in the specimen collection process, but they should follow ensuring proper oral hygiene.

4. A nurse is reinforcing teaching with the mother of a 9-month-old infant regarding appropriate dietary choices. Which of the following observations by the nurse indicates a need for further teaching?

• A. The infant eats the same foods prepared for the rest of the family.
• B. The mother gives the infant finger foods, such as apple slices for a snack.
• C. The infant drinks 2 quarts of whole milk a day.
• D. The infant drinks from a cup with a cover.

Correct answer: C

Rationale: The correct answer is C. Infants should not consume more than 24 ounces of milk a day as it can lead to iron deficiency anemia and other issues. Choices A and B demonstrate appropriate dietary choices for a 9-month-old, as they involve providing the infant with family foods and appropriate finger foods. Choice D is also appropriate as it shows the infant is transitioning to drinking from a cup.

5. The nurse is caring for a child immediately after surgical correction of a ventricular septal defect. Which of the following nursing assessments should be a priority?

• A. Assess nail beds for color and refill
• B. Assess for postoperative arrhythmias
• C. Auscultate for pulmonary congestion
• D. Monitor equality of peripheral pulses

Correct answer: B

Rationale: Postoperative arrhythmias are a common and potentially serious complication after cardiac surgery, making them a priority to monitor. Assessing for postoperative arrhythmias takes precedence over other assessments like checking nail beds for color and refill, auscultating for pulmonary congestion, or monitoring peripheral pulses as arrhythmias can have immediate and severe implications for the child's health.

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