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. The health care provider order reads 'aspirate nasogastric feeding (NG) tube every 4 hours and check pH of aspirate.' The pH of the aspirate is 10. Which action should the nurse take?

• A. Hold the tube feeding and notify the provider
• B. Administer the tube feeding as scheduled
• C. Irrigate the tube with diet cola soda
• D. Apply intermittent suction to the feeding tube

Correct answer: A

Rationale: A pH of 10 indicates improper placement of the NG tube, requiring notification of the provider and holding the feeding. Choice B is incorrect because administering the tube feeding could lead to complications due to the improper placement. Choice C is incorrect as irrigating the tube with diet cola soda is not a standard practice for addressing this issue. Choice D is incorrect as applying intermittent suction does not address the problem of improper placement indicated by the high pH level.

3. The client with congestive heart failure has been educated about proper nutrition. The selection of which lunch indicates the client has learned about sodium restriction?

• A. Cheese sandwich with a glass of 2% milk
• B. Sliced turkey sandwich and canned pineapple
• C. Cheeseburger and baked potato
• D. Mushroom pizza and ice cream

Correct answer: B

Rationale: The correct answer is B: Sliced turkey sandwich and canned pineapple. This lunch choice is suitable for a client with congestive heart failure as it is low in sodium. Sliced turkey is a lean protein choice, and canned pineapple is a low-sodium fruit option. Choice A contains high-sodium items like cheese and 2% milk. Choice C includes a cheeseburger, which is typically high in sodium, and a baked potato could also be high in sodium depending on preparation. Choice D consists of mushroom pizza and ice cream, both of which can be high in sodium, especially in processed or restaurant-prepared forms.

4. During an excretory urogram, which observation made by the nurse indicates a complication?

• A. The client complains of a salty taste in the mouth when the dye is injected
• B. The client's entire body turns a bright red color
• C. The client states 'I have a feeling of getting warm.'
• D. The client gags and complains 'I am getting sick.'

Correct answer: B

Rationale: The observation of the client's entire body turning a bright red color during an excretory urogram indicates a severe reaction to the dye, which is a significant complication. This reaction is likely due to an allergic response and requires immediate medical attention. The other choices do not signify a severe complication: choice A could be a normal taste sensation related to the procedure, choice C may indicate a mild reaction, and choice D could be a common side effect of nausea without indicating a severe complication requiring immediate intervention.

5. Which information is a priority for the client to reinforce after intravenous pyelography?

• A. Eat a light diet for the rest of the day
• B. Rest for the next 24 hours as the preparation and test are tiring.
• C. During waking hours, drink at least 1 8-ounce glass of fluid every hour for the next 2 days
• D. Measure urine output for the next day and immediately notify the healthcare provider if it decreases.

Correct answer: D

Rationale: After intravenous pyelography, monitoring urine output is crucial to assess kidney function and detect any early signs of complications. Decreased urine output could indicate a problem with kidney function or potential complications from the procedure. While rest and hydration are important, the priority lies in monitoring urine output for any abnormalities. Eating a light diet may be recommended, but it is not the priority post-procedure instruction.

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