Nursing Elites

1. 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.

2. An alcoholic and homeless patient is diagnosed with active tuberculosis (TB). Which intervention by the nurse will be most effective in ensuring adherence with the treatment regimen?

• A. Arrange for a friend to administer the medication on schedule.
• B. Give the patient written instructions about how to take the medications.
• C. Teach the patient about the high risk for infecting others unless treatment is followed.
• D. Arrange for a daily noon meal at a community center where the drug will be administered

Correct answer: D

Rationale: Directly observed therapy is the most effective means for ensuring compliance with the treatment regimen for a homeless patient with active tuberculosis. By arranging a daily noon meal at a community center where the drug will be administered, the nurse ensures that the patient is available to receive the medication and can directly observe the patient taking it. This method helps address the challenges faced by homeless individuals, such as lack of a stable living situation. The other options, such as having a friend administer the medication, giving written instructions, or educating about infecting others, may not be as effective in ensuring adherence, especially in the case of a homeless individual with alcoholism.

3. A patient is admitted with active tuberculosis (TB). The nurse should question a healthcare provider's order to discontinue airborne precautions unless which assessment finding is documented?

• A. Chest x-ray shows no upper lobe infiltrates.
• B. TB medications have been taken for 6 months.
• C. Mantoux testing shows an induration of 10 mm.
• D. Three sputum smears for acid-fast bacilli are negative.

Correct answer: D

Rationale: The correct answer is D: Three sputum smears for acid-fast bacilli are negative. Negative sputum smears indicate that Mycobacterium tuberculosis is not present in the sputum, and the patient cannot transmit the bacteria by the airborne route. This finding is crucial for discontinuing airborne precautions. Choice A is incorrect because chest x-rays do not determine the presence of active TB for transmission precautions. Choice B is not directly related to the infectiousness of TB; completing a 6-month course of medication is important for treatment but does not confirm the absence of active disease or infectiousness. Choice C is not relevant to assessing infectiousness; Mantoux testing measures exposure to TB but does not confirm the absence of active infection or infectiousness.

4. A child is diagnosed with a Greenstick Fracture. Which of the following most accurately describes the broken bone?

• A. compound fracture of the fibula
• B. a partial break in a long bone
• C. fracture of the growth plate of the ulna near the wrist
• D. Colles fracture of the tibia

Correct answer: B

Rationale: A Greenstick Fracture is commonly found in children due to their bones being more flexible. This type of fracture occurs when a bone bends and partially breaks, resembling what happens when a green stick from a tree is bent in half. Therefore, the most accurate description of a Greenstick Fracture is 'a partial break in a long bone.' Choice A, 'compound fracture of the fibula,' is incorrect as a Greenstick Fracture is not a compound fracture. Choice C, 'fracture of the growth plate of the ulna near the wrist,' is incorrect as it describes a different type of fracture. Choice D, 'Colles fracture of the tibia,' is incorrect as it refers to a specific type of fracture in a different bone.

5. The patient's symptoms, lack of antibodies for hepatitis, and the abrupt onset of symptoms suggest toxic hepatitis, which can be caused by commonly used over-the-counter drugs such as acetaminophen (Tylenol). Travel to a foreign country and a history of IV drug use are risk factors for viral hepatitis. Corticosteroid use does not cause the symptoms listed.

• A. Hemoglobin
• B. Temperature
• C. Activity level
• D. Albumin level

Correct answer: D

Rationale: The low oncotic pressure caused by hypoalbuminemia is a major pathophysiologic factor in the development of edema. In this case, monitoring the albumin level is crucial to assess the patient's fluid balance and potential for edema. While hemoglobin, temperature, and activity level are important parameters to monitor in a patient's assessment, they are not directly associated with the patient's current symptoms of toxic hepatitis and edema development. Therefore, the correct choice is the albumin level.

Similar Questions