Nursing Elites

1. When assessing a child with acute respiratory infection, what nursing intervention(s) would be appropriate?

• A. Provide safe remedies to relieve the child's sore throat and cough
• B. All of these interventions
• C. Advise the mother to monitor for signs of pneumonia
• D. Ensure proper nutrition to prevent weight loss

Correct answer: B

Rationale: In the management of acute respiratory infection in a child, it is essential to address various aspects of care. Providing safe remedies to relieve symptoms like sore throat and cough (Choice A) helps in managing discomfort. Advising the mother to monitor for signs of pneumonia (Choice C) is crucial for early detection and intervention if complications arise. Ensuring proper nutrition (Choice D) is important for the child's overall health and immune function during illness. Therefore, all the listed interventions are appropriate in managing acute respiratory infection, making Choice B the correct answer. Choices A, C, and D are incorrect on their own as they address only specific aspects of care and not the comprehensive management of acute respiratory infection.

2. The home health care agency can expect to obtain Medicare reimbursement for which home visit performed by a registered nurse (RN) or a practical nurse (PN)?

• A. Assessment of the speech pattern of a mobile adult who had a mild stroke last year.
• B. Safety teaching for an older male client whose wife complains that he uses an unsafe ladder while painting.
• C. Wound care for a client who had a postoperative infection following abdominal surgery two weeks ago.
• D. Evaluation of crutch use by a 65-year-old male client who broke his tibia while snow skiing.

Correct answer: C

Rationale: The correct answer is C because wound care for a postoperative infection is a skilled service that qualifies for Medicare reimbursement. Choices A, B, and D involve assessments, teaching, and evaluation, which may not meet the criteria for Medicare reimbursement as they do not directly involve a skilled nursing service related to a postoperative condition.

3. A client is scheduled to have a blood test for cholesterol and triglycerides the next day. The nurse would tell the client

• A. ''Be sure to eat a fat-free diet until the test.''
• B. ''Do not eat or drink anything but water for 12 hours before the blood test.''
• C. ''Have the blood drawn within 2 hours of eating breakfast.''
• D. ''Stay at the laboratory so 2 blood samples can be drawn an hour apart.''

Correct answer: B

Rationale: Fasting for at least 12 hours is necessary before a cholesterol and triglyceride test to ensure accurate results by avoiding fluctuations that can occur after eating. Choice A is incorrect because a fat-free diet is not required; fasting is. Choice C is incorrect as it suggests having the test right after eating, which can affect the results. Choice D is incorrect as there is no need to stay at the laboratory for 2 blood samples unless specifically instructed by a healthcare provider.

4. A client with a peptic ulcer is scheduled for a vagotomy and pyloroplasty. The nurse explains that the purpose of this surgery is to:

• A. Increase acid secretion
• B. Reduce acid secretion
• C. Promote gastric emptying
• D. Remove the ulcerated area

Correct answer: B

Rationale: The correct answer is B: "Reduce acid secretion." Vagotomy is performed to reduce acid secretion by cutting the vagus nerve, which stimulates acid production. Choices A, C, and D are incorrect. A vagotomy does not increase acid secretion, promote gastric emptying, or remove the ulcerated area. It specifically aims to decrease acid production to help in the healing of peptic ulcers.

5. When admitting a client with Parkinson's disease to the home healthcare service, which nursing diagnosis should have priority in planning care?

• A. Impaired physical mobility related to muscle rigidity and weakness.
• B. Ineffective coping related to depression and dysfunction due to disease progression.
• C. Ineffective breathing pattern related to respiratory muscle weakness.
• D. Fear related to constant possibility of experiencing seizures.

Correct answer: A

Rationale: The correct answer is A: 'Impaired physical mobility related to muscle rigidity and weakness.' For a client with Parkinson's disease, impaired physical mobility is a priority nursing diagnosis because of the characteristic motor symptoms such as muscle rigidity, bradykinesia, and postural instability. Addressing impaired physical mobility is crucial to enhance the client's quality of life. Choices B, C, and D are not the priority nursing diagnoses for a client with Parkinson's disease. Ineffective coping (Choice B) and fear of seizures (Choice D) may be concerns but are not the priority. Ineffective breathing pattern (Choice C) is not typically associated with Parkinson's disease.

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