Nursing Elites

1. While suctioning the endotracheal tube of an adult client, what level of pressure should the nurse apply?

• A. 70-80 mmHg
• B. 100-120 mmHg
• C. 150-170 mmHg
• D. 200 mmHg

Correct answer: B

Rationale: When suctioning the endotracheal tube of an adult client, the nurse should set the suction apparatus at a level no higher than 150 mmHg, with a preferable level between 100 and 120 mmHg. Suction pressure that is too high can contribute to the client's hypoxia. Alternatively, too low suction pressure may not clear adequate amounts of secretions. Choice A (70-80 mmHg) is too low and may not effectively clear secretions. Choices C (150-170 mmHg) and D (200 mmHg) are too high and can potentially harm the client by causing hypoxia or damaging the airway.

2. A two-year-old child has sustained an injury to the leg and refuses to walk. The nurse in the emergency department documents swelling of the lower affected leg. Which of the following does the nurse suspect is the cause of the child's symptoms?

• A. Possible fracture of the tibia.
• B. Bruising of the gastrocnemius muscle.
• C. Possible fracture of the radius.
• D. No anatomic injury, the child wants his mother to carry him.

Correct answer: A

Rationale: The child's refusal to walk, along with swelling of the lower leg, indicates a possible fracture, specifically of the tibia. Fractures can cause pain and swelling, leading to difficulty or refusal to bear weight on the affected limb. Choice B, bruising of the gastrocnemius muscle, would not typically result in the child refusing to walk. Choice C, a possible fracture of the radius, is less likely given the location of the swelling and the associated refusal to walk. Choice D, stating no anatomic injury and attributing the child's behavior to wanting to be carried by the mother, is incorrect as the physical findings suggest a potential fracture that needs to be evaluated further.

3. The mother of a child who had a cleft palate repair 4 days ago is receiving home care instructions. Which statement by the mother indicates the need for further instruction?

• A. ''I will use a short nipple on the bottle.''
• B. ''I should avoid using straws for drinking.''
• C. ''I can give my child the pacifier in 2 weeks.''
• D. ''I may give my baby food mixed with water.''

Correct answer: B

Rationale: The correct answer is ''I should avoid using straws for drinking.'' After a cleft palate repair, the child should avoid straws, pacifiers, spoons, and fingers near the mouth for 7 to 10 days to prevent injury to the surgical site. Allowing the child to use a straw can create negative pressure in the mouth, potentially disrupting the healing process. The other options are appropriate postoperative instructions for a child who had a cleft palate repair and do not pose a risk to the surgical site.

4. A patient with acute dyspnea is scheduled for a spiral computed tomography (CT) scan. Which information obtained by the nurse is a priority to communicate to the health care provider before the CT?

• A. Allergy to shellfish
• B. Apical pulse of 104
• C. Respiratory rate of 30
• D. Oxygen saturation of 90%

Correct answer: A

Rationale: Because iodine-based contrast media is used during a spiral CT, the patient may need to have the CT scan without contrast or be premedicated before injection of the contrast media. The increased pulse, low oxygen saturation, and tachypnea all indicate a need for further assessment or intervention but do not indicate a need to modify the CT procedure.

5. A 16-month-old child has just been admitted to the hospital. As the nurse assigned to this child enters the hospital room for the first time, the toddler runs to the mother, clings to her, and begins to cry. What would be the initial action by the nurse?

• A. Arrange to change client care assignments
• B. Explain that this behavior is expected
• C. Discuss the appropriate use of 'time-out'
• D. Explain that the child needs extra attention

Correct answer: B

Rationale: When encountering a 16-month-old child exhibiting fear of strangers by clinging to the parent and crying, it is essential for the nurse to explain that this behavior is expected. Fear of strangers typically emerges around 6-8 months of age and can continue into the toddler years and beyond. This behavior is a normal part of development as the child is displaying attachment and trust in familiar caregivers. Changing client care assignments, discussing 'time-out,' or suggesting the child needs extra attention are not appropriate initial actions in this situation. Changing care assignments is unnecessary and does not address the child's emotional needs. Discussing 'time-out' is not relevant as it pertains to discipline strategies for older children. Suggesting the child needs extra attention may misinterpret the situation; the child's behavior is a normal response to a new environment and does not necessarily indicate a need for additional attention.

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