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. A client is receiving intravenous antibiotics for the treatment of a severe infection. Which of these assessments is a priority for the nurse to perform?

• A. Monitor the client's temperature
• B. Assess the client's pain level
• C. Check the intravenous (IV) site for signs of phlebitis
• D. Monitor the client's respiratory status

Correct answer: C

Rationale: When a client is receiving intravenous antibiotics, checking the IV site for signs of phlebitis is a priority assessment for the nurse. Phlebitis is an inflammation of the vein, which can lead to serious complications such as infection and thrombosis. Monitoring the IV site helps prevent these complications and ensures the safe delivery of antibiotics. While monitoring the client's temperature, pain level, and respiratory status are important assessments, they are not the priority in this scenario where IV antibiotic administration requires close monitoring for complications like phlebitis.

3. When introducing solid foods to an infant, what food should be recommended to be introduced first?

• A. Strained fruits
• B. Pureed meats
• C. Cooked egg whites
• D. Iron-fortified cereal

Correct answer: D

Rationale: When introducing solid foods to infants, iron-fortified cereal is usually recommended as the first food due to its high nutritional value and the importance of iron for the baby's development. Strained fruits (choice A) are often introduced later due to their higher sugar content. Pureed meats (choice B) and cooked egg whites (choice C) are usually introduced after iron-fortified cereal to provide additional sources of protein and other nutrients.

4. A client who is to have antineoplastic chemotherapy tells the nurses of a fear of being sick all the time and wishes to try acupuncture. Which of these beliefs stated by the client would be incorrect about acupuncture?

• A. Some needles go as deep as 3 inches, depending on where they're placed in the body and what the treatment is for. The needles are usually left in for 15 to 30 minutes.
• B. In traditional Chinese medicine, imbalances in the basic energetic flow of life — known as qi or chi — are thought to cause illness.
• C. The flow of life is believed to flow through major pathways in your body rather than nerve clusters.
• D. By inserting extremely fine needles into some of the over 400 acupuncture points in various combinations, it is believed that energy flow will rebalance to allow the body's natural healing mechanisms to take over.

Correct answer: C

Rationale: The belief stated in option C is incorrect about acupuncture. Acupuncture is based on the concept of qi flowing through major pathways in the body, known as meridians, rather than nerve clusters. This traditional Chinese medicine practice aims to balance the flow of qi to promote health and healing. Options A, B, and D are consistent with the principles of acupuncture and are not incorrect beliefs. Option A describes the depth and duration of needle placement, option B explains the role of imbalances in qi flow causing illness, and option D outlines how acupuncture helps rebalance energy flow for the body's natural healing mechanisms.

5. A client has received 2 units of whole blood today following an episode of GI bleeding. Which of the following laboratory reports would the nurse monitor most closely?

• A. Bleeding time
• B. Hemoglobin and hematocrit
• C. White blood cells
• D. Platelets

Correct answer: B

Rationale: Corrected Hemoglobin and hematocrit levels should be monitored closely after blood transfusions to assess the effectiveness and identify any complications. Monitoring hemoglobin and hematocrit levels helps evaluate the patient's oxygen-carrying capacity and blood volume. While platelets are crucial for clotting, they are not typically affected immediately after a blood transfusion. White blood cell count monitoring is more relevant in assessing infection or immune response, not directly related to a blood transfusion. Bleeding time measures platelet function, which is not the primary concern immediately after a blood transfusion.

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