Nursing Elites

1. The nurse is discussing with a group of students the disease Kawasaki. What statement made by a student about Kawasaki disease is incorrect?

• A. It is also called mucocutaneous lymph node syndrome because it affects the mucous membranes (inside the mouth, throat, and nose), skin, and lymph nodes.
• B. In the second phase of the disease, findings include peeling of the skin on the hands and feet with joint and abdominal pain.
• C. Kawasaki disease occurs most often in boys, children younger than age 5, and children of Hispanic descent.
• D. Initially findings are a sudden high fever, usually above 104 degrees Fahrenheit, which lasts 1 to 2 weeks.

Correct answer: C

Rationale: The correct answer is C. Kawasaki disease occurs most often in boys and children younger than age 5, but there is no specific predisposition to children of Hispanic descent. Choice A is accurate, as Kawasaki disease does affect mucous membranes, skin, and lymph nodes. Choice B is correct, as peeling of the skin on the hands and feet with joint and abdominal pain are findings in the second phase of the disease. Choice D is accurate since initially, there is a sudden high fever that lasts 1 to 2 weeks.

2. An 86-year-old nursing home resident who has decreased mental status is hospitalized with pneumonic infiltrates in the right lower lobe. When the nurse assists the client with a clear liquid diet, the client begins to cough. What should the nurse do next?

• A. Add a thickening agent to the fluids
• B. Check the client's gag reflex
• C. Feed the client only solid foods
• D. Increase the rate of intravenous fluids

Correct answer: B

Rationale: Checking the client's gag reflex is the appropriate action in this scenario. It helps assess the client's ability to swallow safely without the risk of aspiration. Adding a thickening agent to the fluids (Choice A) may be considered later if swallowing difficulties persist. Feeding the client only solid foods (Choice C) can increase the risk of aspiration in this case, and increasing the rate of intravenous fluids (Choice D) does not address the swallowing concern.

3. 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.

4. A client with pneumococcal pneumonia had been started on antibiotics 16 hours ago. During the nurse's initial evening rounds, the nurse notices a foul smell in the room. The client makes all of these statements during their conversation. Which statement would alert the nurse to a complication?

• A. I have a sharp pain in my chest when I take a breath.
• B. I have been coughing up foul-tasting, brown, thick sputum.
• C. I have been sweating all day.
• D. I feel hot off and on.

Correct answer: B

Rationale: Coughing up foul-tasting, brown, thick sputum suggests a possible abscess or secondary infection, requiring attention. Choice A may indicate pleurisy, but the focus should be on the sputum. Choice C may be non-specific and could be related to the infection or fever. Choice D is non-specific and may be expected during an infection.

5. A nurse is reinforcing teaching with the parent of a toddler about appropriate snacks. Which of the following foods should the nurse include in the teaching?

• A. Sliced bananas
• B. Raw celery
• C. Peanut butter
• D. Marshmallows

Correct answer: A

Rationale: The correct answer is A: Sliced bananas. Sliced bananas are a healthy and safe snack option for toddlers as they provide essential nutrients and are easy to chew. Bananas are a good source of potassium and fiber. Choice B, raw celery, may pose a choking hazard for toddlers due to its stringy texture. Choice C, peanut butter, can also be a choking hazard and may not be suitable for all toddlers due to potential allergies. Choice D, marshmallows, are high in sugar and low in nutrients, making them an unhealthy choice for toddler snacks.

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