Nursing Elites

1. The nurse is teaching parents about the treatment plan for a 2-week-old infant with Tetralogy of Fallot. While awaiting future surgery, the nurse instructs the parents to immediately report

• A. Loss of consciousness
• B. Feeding problems
• C. Poor weight gain
• D. Fatigue with crying

Correct answer: A

Rationale: The correct answer is 'Loss of consciousness.' While parents should report any concerning observations, they need to call the healthcare provider immediately if the infant experiences a loss of consciousness. This change in alertness may indicate anoxia, which can be life-threatening. Tetralogy of Fallot is a congenital heart defect characterized by four main features: pulmonic stenosis, ventricular septal defect, overriding aorta, and right ventricular hypertrophy. Surgery for Tetralogy of Fallot may be delayed or done in stages. Reporting loss of consciousness is crucial due to the potential seriousness of the condition. Feeding problems, poor weight gain, and fatigue with crying are important issues but do not require immediate reporting like loss of consciousness does.

2. A patient who was admitted the previous day with pneumonia complains of a sharp pain of 7 (based on a 0 to 10 scale) whenever taking a deep breath. Which action will the nurse take next?

• A. Auscultate breath sounds.
• B. Administer PRN morphine.
• C. Have the patient cough forcefully.
• D. Notify the patient's healthcare provider.

Correct answer: A

Rationale: The patient's complaint of sharp pain when taking a deep breath is concerning for pleurisy or pleural effusion. The nurse should auscultate breath sounds to assess for a pleural friction rub or decreased breath sounds, which could indicate these conditions. It is crucial to gather assessment data before initiating any pain medications. Asking the patient to cough forcefully may exacerbate the pain and should be avoided until further assessment. Contacting the healthcare provider should be based on the assessment findings; therefore, it is premature to notify the provider without conducting a thorough assessment first.

3. A client with a new colostomy is being taught how to care for the colostomy bag. Which statement from the client indicates the need for more education?

• A. I can clean the skin around the ostomy site with soap and water when I change the bag.
• B. I should irrigate the stoma regularly to avoid buildup of gas and odor.
• C. I need to wait 30 minutes after I irrigate to replace the colostomy bag.
• D. I should change the bag when it is one-third to one-fourth full.

Correct answer: C

Rationale: A client with a new colostomy requires education on proper colostomy care. Waiting 30 minutes after irrigating to replace the colostomy bag is unnecessary. The client may reapply the bag once the skin is dry. Cleaning the skin around the ostomy site with soap and water, irrigating the stoma regularly to prevent gas and odor buildup, and changing the bag when it is one-third to one-fourth full are appropriate actions. Therefore, the statement indicating the need for more education is the one suggesting a specific time interval for bag replacement after irrigation.

4. Which of the following complaints is characteristic of a patient with Bell's Palsy?

• A. Paralysis of the right or left arm
• B. Malfunction of a certain cranial nerve
• C. A sub-condition of Cerebral Palsy
• D. A side effect of a stroke

Correct answer: B

Rationale: Bell's Palsy is characterized by the dysfunction of the Facial nerve, which is cranial nerve VII. This dysfunction leads to facial muscle weakness or paralysis, not affecting the arms. Choice A is incorrect as Bell's Palsy specifically involves facial muscles, not the arms. Choice C is incorrect as it incorrectly associates Bell's Palsy with a different condition, Cerebral Palsy. Choice D is incorrect as Bell's Palsy is not a side effect of a stroke but rather a distinct condition with its own etiology.

5. What nursing intervention demonstrates that the nurse understands the priority nursing diagnosis when caring for oral cancer patients with extensive tumor involvement and/or a high amount of secretions?

• A. The nurse uses a pen pad to communicate with the patient
• B. The nurse provides oral care every 2 hours
• C. The nurse listens for bowel sounds every 4 hours
• D. The nurse suctions as needed and elevates the head of the bed

Correct answer: D

Rationale: The correct answer is to suction as needed and elevate the head of the bed. This intervention is crucial for managing Ineffective Airway Clearance, which is the priority nursing diagnosis in oral cancer patients with extensive tumor involvement and/or a high amount of secretions. Suctioning helps clear secretions that may obstruct the airway, while elevating the head of the bed promotes optimal respiratory function. Providing oral care every 2 hours may be important for overall oral health but is not directly related to addressing the priority diagnosis. Listening for bowel sounds every 4 hours is more relevant to gastrointestinal assessment and not specific to managing airway clearance issues in oral cancer patients.

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