Nursing Elites

1. A 2-year-old child with laryngotracheobronchitis (LTB) is fussy and restless in the oxygen tent. The oxygen level in the tent is 25%, and blood gases are normal. What would be the correct action by the nurse?

• A. Restrain the child in the tent and notify the health care provider.
• B. Increase the oxygen concentration in the tent.
• C. Take the child out of the tent and into the playroom.
• D. Ask the mother for help in comforting the child.

Correct answer: B

Rationale: The child with LTB should be placed in the mist tent with 30% oxygen. Restlessness is caused by poor oxygenation. The child should not be taken out of the oxygenated tent. While the mother could be asked to help comfort the child, and the health care provider may be notified, the priority is to set the oxygen at the correct level.

2. The nurse is caring for a client with a suspected stroke. Which assessment finding is most indicative of a stroke?

• A. Chest pain
• B. Sudden confusion and difficulty speaking
• C. Gradual onset of weakness in the legs
• D. Nausea and vomiting

Correct answer: B

Rationale: The correct answer is B: Sudden confusion and difficulty speaking. These are classic signs of a stroke, indicating a neurological deficit that requires urgent medical attention. Choices A, C, and D are less indicative of a stroke. Chest pain is more commonly associated with cardiac issues, gradual onset of weakness in the legs could be related to other conditions like peripheral neuropathy, and nausea/vomiting may suggest gastrointestinal problems rather than a stroke.

3. A male client with heart failure calls the clinic and reports that he cannot put his shoes on because they are too tight. Which additional information should the nurse obtain?

• A. What time he took his medication?
• B. Has his weight changed in the last several days?
• C. Is he still able to tighten his belt buckle?
• D. How many hours he slept last night?

Correct answer: B

Rationale: The correct answer is B: 'Has his weight changed in the last several days?' Sudden weight gain can indicate fluid retention, which is a common symptom of worsening heart failure. The inability to put on tight shoes can be due to fluid retention leading to swelling in the feet and ankles. Choices A, C, and D do not directly address the potential fluid retention issue and are less relevant in this scenario.

4. How should the nurse record the observation of a child with Duchenne muscular dystrophy rising from the floor by walking up the thighs with the hands?

• A. Hand assistance
• B. Leg crawling
• C. Gowers sign
• D. Bright sign

Correct answer: C

Rationale: The correct term for a child with Duchenne muscular dystrophy rising from the floor by walking up the thighs with the hands is known as the Gowers sign. This maneuver is characteristic of Duchenne muscular dystrophy due to proximal muscle weakness. Choices A, B, and D are incorrect because they do not specifically describe the action of walking up the thighs with the hands, which is a distinctive feature of the Gowers sign.

5. Which of the following is a priority assessment for a client receiving intravenous vancomycin?

• A. Respiratory rate
• B. Blood pressure
• C. Urine output
• D. Hearing acuity

Correct answer: D

Rationale: The correct answer is D, Hearing acuity. Vancomycin is known to cause ototoxicity, which can result in hearing loss. Monitoring the client's hearing acuity is crucial to detect any early signs of ototoxicity. Assessing respiratory rate, blood pressure, and urine output are important assessments in general patient care but are not the priority when specifically monitoring for vancomycin-induced ototoxicity.

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