Nursing Elites

1. A 16-year-old adolescent with cystic fibrosis is admitted to the hospital with a respiratory infection. The nurse is teaching the adolescent about the importance of airway clearance techniques. Which statement by the adolescent indicates a need for further teaching?

• A. I should do my airway clearance exercises every day.
• B. I don’t need to do my airway clearance exercises if I feel okay.
• C. Airway clearance helps prevent mucus buildup in my lungs.
• D. I should continue my airway clearance routine even when I’m not sick.

Correct answer: B

Rationale: The correct answer is B. Airway clearance exercises are essential for individuals with cystic fibrosis to prevent mucus buildup in their lungs. It is crucial to perform these exercises regularly, even when feeling well, to maintain lung health and prevent complications. Choice A is correct as doing airway clearance exercises daily is necessary. Choice C is also accurate as airway clearance does indeed help prevent mucus buildup. Choice D is correct as it is important to continue the airway clearance routine even when not sick to maintain lung health. Choice B is incorrect because stating that airway clearance exercises are unnecessary when feeling okay demonstrates a misunderstanding of the importance of consistent airway clearance in cystic fibrosis management.

2. A 16-year-old female student with a history of asthma controlled with both an oral antihistamine and an albuterol (Proventil) metered-dose inhaler (MDI) comes to the school nurse. The student complains that she cannot sleep at night, feels shaky, and her heart feels like it is 'beating a mile a minute.' Which information is most important for the nurse to obtain?

• A. When she last took the antihistamine.
• B. When her last asthma attack occurred.
• C. Duration of most asthma attacks.
• D. How often the MDI is used daily.

Correct answer: D

Rationale: The most important information for the nurse to obtain is how often the MDI is used daily. This is crucial to assess if the symptoms of insomnia, shakiness, and rapid heart rate are related to overuse of the inhaler, leading to potential side effects such as systemic effects of beta-2 agonists.

3. A male adolescent who is newly diagnosed with a seizure disorder receives a prescription for an anticonvulsant. Which statement indicates the client is at risk for non-compliance with life-long medication management?

• A. I hope I will be able to drive while taking these pills.
• B. My friends will think I am a freak if I take these pills.
• C. I don't want my parents monitoring my medications.
• D. I will take the pills at home so others will not see me.

Correct answer: B

Rationale: The statement 'My friends will think I am a freak if I take these pills' indicates concerns about peer perception, which can lead to non-compliance in adolescents. Peer pressure and fear of social stigma can significantly impact medication adherence in this age group. Option B is the most concerning response as it reflects the client's worry about how others perceive him for taking medication, potentially leading to non-compliance due to social pressures. Choices A, C, and D do not directly address societal perception or peer pressure, making them less likely to impact the client's medication adherence negatively.

4. The child is 3 years old and is 2 hours postop from a cardiac catheterization via the right femoral artery. Which assessment finding indicates arterial obstruction?

• A. Blood pressure is decreasing, and the pulse is rapid and irregular.
• B. The right foot feels cool to the touch and appears pale and blanched.
• C. The pulse distal to the femoral artery is weaker in the left foot than the right foot.
• D. The pressure dressing at the right femoral area is damp and oozing blood.

Correct answer: B

Rationale: A cool, pale, and blanched foot is indicative of arterial obstruction, leading to poor blood flow. This finding requires immediate intervention to prevent further complications such as tissue damage or necrosis. Monitoring for signs of arterial compromise, such as color changes, temperature, and capillary refill, is crucial in detecting and managing vascular complications post-cardiac catheterization. Choices A, C, and D do not directly indicate arterial obstruction. While a decreasing blood pressure and rapid, irregular pulse may suggest compromise, these findings are more nonspecific. A weaker pulse distal to the femoral artery indicates reduced perfusion but not necessarily arterial obstruction. Finally, a damp, oozing pressure dressing suggests a dressing issue rather than arterial obstruction.

5. During a well baby visit, the parents explain that a soft bulge appears in the groin of their 4-month-old son when he cries or strains during stooling. The infant is scheduled for surgical repair of the inguinal hernia in two weeks. What should the parent be instructed to do if the hernia becomes incarcerated prior to the surgery?

• A. Use a rectal thermometer to strain during stooling.
• B. Gently manipulate the hernia for reduction.
• C. Offer oral electrolyte fluids for comfort.
• D. Give acetaminophen or aspirin for crying.

Correct answer: B

Rationale: In the case of an incarcerated inguinal hernia, gentle manipulation can sometimes help in reducing it before surgery. This action should be taken cautiously and immediately followed by seeking medical attention. It is important to note that attempting reduction should be done by a healthcare professional, and parents should be advised to seek urgent medical care if the hernia becomes incarcerated. Using a rectal thermometer to strain during stooling (Choice A) is not the correct approach for an incarcerated hernia and can worsen the condition. Offering oral electrolyte fluids for comfort (Choice C) or giving acetaminophen or aspirin for crying (Choice D) are not appropriate interventions for an incarcerated hernia and may delay necessary medical treatment.

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