Nursing Elites

1. After changing to a new brand of laundry detergent, an adult male reports that he has a fine itchy rash. Which assessment finding warrants immediate intervention by the nurse?

• A. Bilateral Wheezing
• B. Urticaria
• C. Peripheral edema
• D. Elevated blood pressure

Correct answer: B

Rationale: The correct answer is B: Urticaria. An itchy rash following a change in detergent may indicate an allergic reaction, specifically urticaria (hives), which requires immediate attention. Urticaria can be a sign of a severe allergic reaction, such as anaphylaxis. Bilateral wheezing (choice A) may suggest respiratory issues like asthma but is not directly related to the skin rash. Peripheral edema (choice C) and elevated blood pressure (choice D) are not typically associated with an allergic reaction to laundry detergent and would not be the priority assessment findings in this scenario.

2. A 60-year-old male with type 2 diabetes mellitus tells the nurse that he is going to join a gym and start working out. Which information is most important for the nurse to obtain?

• A. Recent serum cholesterol levels
• B. Presence of calf pain during exercise
• C. Average weight gain or loss in the last year
• D. Exercise tolerance test with EKG results

Correct answer: B

Rationale: The most important information for the nurse to obtain in this scenario is the presence of calf pain during exercise. Calf pain during exercise could indicate peripheral vascular issues, such as peripheral artery disease, which is crucial to address before starting an exercise program. High cholesterol levels (choice A) may be important but are not as immediately relevant as assessing for peripheral vascular issues. Average weight gain or loss (choice C) may provide some insight into the patient's overall health status but is not as critical as assessing for potential vascular complications. An exercise tolerance test with EKG results (choice D) may be valuable in assessing cardiovascular fitness but is not as crucial as evaluating for peripheral vascular issues given the patient's symptoms.

3. What information should the nurse include in the discharge teaching plan of a client with low back pain who is taking cyclobenzaprine to control muscle spasms?

• A. Take this medication with or without food
• B. Avoid using heat or ice on injured muscles while taking this medication
• C. Use cold and allergy medications only as directed by a healthcare provider
• D. Discontinue all nonsteroidal anti-inflammatory medications

Correct answer: C

Rationale: The correct answer is C: 'Use cold and allergy medications only as directed by a healthcare provider.' It is essential to inform the client not to self-medicate with cold and allergy medications or make changes without consulting a healthcare provider to prevent potential drug interactions or adverse effects. Choice A is incorrect because cyclobenzaprine can be taken with or without food, so there is no specific requirement to take it on an empty stomach. Choice B is incorrect because using heat or ice on injured muscles while taking cyclobenzaprine is generally safe and can help with symptom management. Choice D is also incorrect because discontinuing nonsteroidal anti-inflammatory medications should be done under the guidance of a healthcare provider, but it is not a direct concern related to taking cyclobenzaprine for muscle spasms.

4. A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant. While providing care, the nurse finds the radiation implant in the bed. What action should the nurse take?

• A. Call the radiology department
• B. Reinsert the implant into the vagina
• C. Apply double gloves to retrieve the implant for disposal
• D. Place the implant in a lead container using long-handled forceps

Correct answer: D

Rationale: The correct action for the nurse to take when finding a radiation implant in the bed is to place the implant in a lead container using long-handled forceps. This action is crucial to minimize radiation exposure to both the patient and healthcare providers and ensure the safe disposal of the radioactive material. Calling the radiology department (choice A) may lead to unnecessary delays in addressing the immediate safety concern. Reinserting the implant into the vagina (choice B) is contraindicated and can cause harm. Applying double gloves to retrieve the implant for disposal (choice C) is not adequate for ensuring proper containment and handling of the radioactive implant, which requires specialized equipment like a lead container and long-handled forceps.

5. The parents of a child who had surgical repair of a myelomeningocele are being taught how to change an occlusive dressing on the child’s back. Which statement by the parents indicates that they understand this procedure?

• A. When changing the dressing, the tape should be removed slowly to prevent trauma to the skin
• B. To prevent infection, the dressing should be kept dry to avoid excess moisture
• C. The skin incision should be kept moist to promote healing and prevent dryness
• D. The incision should be protected from fecal contamination by an intact dressing

Correct answer: D

Rationale: The correct answer is D because protecting the incision from fecal contamination is essential to prevent infection and promote healing in a child with a myelomeningocele. This is crucial as fecal matter can introduce harmful bacteria to the wound. Choice A is incorrect as removing the tape slowly to prevent trauma to the skin is a general guideline but not specific to preventing infection. Choice B is incorrect because keeping the dressing dry can lead to complications as the wound needs a moist environment to heal properly. Choice C is incorrect as keeping the skin incision moist may promote infection and delay healing, making it an incorrect statement for postoperative care.

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