Nursing Elites

1. The nurse is caring for a child immediately after surgical correction of a ventricular septal defect. Which of the following nursing assessments should be a priority?

• A. Assess nail beds for color and refill
• B. Assess for postoperative arrhythmias
• C. Auscultate for pulmonary congestion
• D. Monitor equality of peripheral pulses

Correct answer: B

Rationale: Postoperative arrhythmias are a common and potentially serious complication after cardiac surgery, making them a priority to monitor. Assessing for postoperative arrhythmias takes precedence over other assessments like checking nail beds for color and refill, auscultating for pulmonary congestion, or monitoring peripheral pulses as arrhythmias can have immediate and severe implications for the child's health.

2. A nurse is reinforcing dietary teaching with a client who has a burn injury and adheres to a strict vegan diet. Which of the following food choices should the nurse recommend?

• A. Tuna salad
• B. Fresh fruit
• C. Vegetables
• D. Beans

Correct answer: D

Rationale: Beans are an excellent choice for a client with a burn injury who follows a strict vegan diet. They are a rich source of protein, essential for healing, making them the most suitable option among the choices provided. Tuna salad (choice A) is not suitable for a vegan diet as it contains animal products. While fresh fruit (choice B) and vegetables (choice C) are healthy options, they may not provide sufficient protein needed for healing from a burn injury.

3. A 14-year-old with a history of sickle cell disease is admitted to the hospital with a diagnosis of vaso-occlusive crisis. Which statement by the client would be most indicative of the etiology of this crisis?

• A. I knew this would happen. I've been eating too much red meat lately.
• B. I really enjoyed my fishing trip yesterday. I caught 2 fish.
• C. I have really been working hard practicing with the debate team at school.
• D. I went to the healthcare provider last week for a cold, and I have gotten worse.

Correct answer: D

Rationale: The correct answer is D because a recent illness, such as a cold, can trigger a vaso-occlusive crisis in sickle cell disease. This crisis is often precipitated by infections or other illnesses that cause a systemic inflammatory response, leading to vaso-occlusion. Choices A, B, and C do not directly relate to the etiology of a vaso-occlusive crisis in sickle cell disease, making them incorrect.

4. During the care of a client with a salmonella infection, what is the primary nursing intervention to limit transmission?

• A. Wash hands thoroughly before and after client contact
• B. Wear gloves when in contact with body secretions
• C. Double glove when in contact with feces or vomitus
• D. Wear gloves when disposing of contaminated linens

Correct answer: A

Rationale: The correct answer is to wash hands thoroughly before and after client contact when caring for a client with a salmonella infection. This approach is crucial in preventing the transmission of the infection. While wearing gloves when in contact with body secretions (Choice B), double gloving when in contact with feces or vomitus (Choice C), and wearing gloves when disposing of contaminated linens (Choice D) are important infection control measures, the primary intervention to limit the spread of salmonella is proper hand hygiene.

5. The nurse is caring for a client with a new diagnosis of diabetes mellitus. Which of these statements made by the client indicates a need for further teaching?

• A. I will monitor my blood glucose levels regularly and keep a record to show my healthcare provider.
• B. I will follow my meal plan and exercise regularly to help manage my blood sugar levels.
• C. I will stop taking my medications if my blood sugar levels are normal.
• D. I will continue to take my medications even if I feel better.

Correct answer: C

Rationale: Choice C indicates a need for further teaching because stopping medications when blood sugar levels are normal can lead to uncontrolled blood sugar levels if the individual does not understand the importance of medication adherence in managing diabetes. Choices A, B, and D are correct statements that demonstrate good understanding of managing diabetes, such as monitoring blood glucose levels, following a meal plan, exercising regularly, and adhering to medication even when feeling better.

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