Nursing Elites

1. The mother of a child who has been diagnosed with varicella asks the nurse when the child can return to school. When is the child no longer contagious?

• A. When the fever dissipates
• B. After the incubation period
• C. When the lesions have healed
• D. When the lesions are crusted over

Correct answer: D

Rationale: The correct answer is D: 'When the lesions are crusted over.' Varicella is no longer contagious once the lesions are dry and crusted. This stage indicates that the active viral shedding has significantly decreased, reducing the risk of transmission. Choice A, 'When the fever dissipates,' is incorrect because the presence of fever does not necessarily correlate with the contagiousness of varicella. Choice B, 'After the incubation period,' is incorrect as the incubation period occurs before the onset of symptoms and is not relevant to determining contagiousness. Choice C, 'When the lesions have healed,' is incorrect as healed lesions can still be contagious if they are not crusted over.

2. Which instruction should the nurse provide a client who was recently diagnosed with Raynaud's disease?

• A. Avoid cold temperatures completely.
• B. Take medications only during flare-ups.
• C. Wear gloves when removing packages from the freezer.
• D. Limit physical activity to avoid stress.

Correct answer: C

Rationale: The correct instruction for a client with Raynaud's disease is to wear gloves when handling cold items to prevent vasospasm. Raynaud's disease is characterized by vasospasm in response to cold or stress, leading to reduced blood flow to extremities. Wearing gloves when removing packages from the freezer helps minimize exposure to cold temperatures and can prevent triggering vasospasms. Choices A, B, and D are incorrect. Avoiding cold temperatures completely is impractical and may not always be possible. Taking medications only during flare-ups does not address prevention strategies, and limiting physical activity to avoid stress is not a primary intervention for Raynaud's disease.

3. A client with cancer is receiving chemotherapy with a known vesicant. The client's IV has been in place for 72 hours. The nurse determines that a new IV site cannot be obtained and leaves the present IV in place. What is the greatest clinical risk related to this situation?

• A. Impaired skin integrity
• B. Fluid volume excess
• C. Acute pain and anxiety
• D. Peripheral neurovascular dysfunction

Correct answer: A

Rationale: The correct answer is A: Impaired skin integrity. In this situation, the greatest clinical risk is related to impaired skin integrity due to the potential extravasation of the vesicant. Vesicants are substances that can cause severe tissue damage if they leak into the surrounding tissues. Choices B, C, and D are not the most significant risks in this scenario. Fluid volume excess, acute pain, and peripheral neurovascular dysfunction are not directly associated with leaving the IV in place with a known vesicant for an extended period.

4. When caring for a client with nephrotic syndrome, which assessment is most important for the nurse to obtain?

• A. Daily weight
• B. Vital signs
• C. Level of consciousness
• D. Bowel sounds

Correct answer: A

Rationale: Corrected Rationale: Daily weight is the most important assessment to monitor fluid balance in clients with nephrotic syndrome. In nephrotic syndrome, excessive protein loss leads to fluid retention and edema. Monitoring daily weight allows the nurse to assess fluid status accurately. Vital signs, while important, may not directly reflect fluid balance changes in nephrotic syndrome. Level of consciousness and bowel sounds are not typically the primary assessments for monitoring fluid balance in clients with nephrotic syndrome.

5. 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.

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