Nursing Elites

1. A 7-year-old is admitted to the hospital with persistent vomiting, and a nasogastric tube attached to low intermittent suction is applied. Which finding is most important for the nurse to report to the healthcare provider?

• A. Gastric output of 100 mL in the last 8 hours.
• B. Shift intake of 640 mL IV fluids plus 30 mL PO ice chips.
• C. Serum potassium of 3.0 mEq/L.
• D. Serum pH of 7.45.

Correct answer: C

Rationale: A serum potassium level of 3.0 mEq/L is significantly low and indicates hypokalemia, which can lead to serious complications such as cardiac arrhythmias. Therefore, it is crucial for the nurse to report this finding promptly to the healthcare provider for immediate intervention. The other findings are not as critical in this situation. Gastric output of 100 mL in the last 8 hours may be expected in a patient with persistent vomiting. The shift intake of IV fluids and ice chips indicates fluid replacement, which is important but not as urgent as correcting electrolyte imbalances. A serum pH of 7.45 is within the normal range and does not indicate an immediate concern.

2. A 9-year-old child is brought to the clinic with complaints of fatigue, pallor, and shortness of breath. The nurse notes that the child has a history of iron-deficiency anemia. What is the nurse’s priority action?

• A. Administer iron supplements as prescribed
• B. Monitor the child’s hemoglobin levels
• C. Educate the parents about dietary sources of iron
• D. Notify the healthcare provider

Correct answer: A

Rationale: In a child with a history of iron-deficiency anemia presenting with symptoms of fatigue, pallor, and shortness of breath, the priority action for the nurse is to administer iron supplements as prescribed. Iron supplementation is essential to treat iron-deficiency anemia and improve the child's symptoms promptly. Monitoring hemoglobin levels is important but administering iron supplements takes precedence to address the underlying cause. Educating parents about dietary iron sources is valuable for prevention but not the immediate priority. Notifying the healthcare provider may be necessary but should not delay the initiation of treatment with iron supplements.

3. When should a mother introduce solid foods to her 4-month-old infant? The mother states that her mother suggests putting rice cereal in the baby's bottle. The nurse should instruct the mother to introduce solid foods when her child exhibits which behavior?

• A. Stops rooting when hungry
• B. Opens mouth when food is offered
• C. Awakens once for nighttime feedings
• D. Gives up a bottle for a cup

Correct answer: B

Rationale: Introducing solid foods when the child opens their mouth for food is important to ensure readiness for solids. This behavior indicates the infant's interest and readiness for new textures and flavors, promoting safe and successful introduction to solid foods. The other choices are not indicative of the infant's readiness for solid foods: A - stopping rooting is a reflex action, C - awakening for nighttime feedings is a normal behavior, and D - transitioning from a bottle to a cup is a developmental milestone unrelated to solid food introduction.

4. A 15-year-old adolescent with anorexia nervosa is admitted to the hospital for severe weight loss. The nurse notes that the client has dry skin, brittle hair, and is severely underweight. What is the nurse’s priority intervention?

• A. Establish a therapeutic relationship with the client
• B. Monitor the client’s vital signs frequently
• C. Initiate a structured eating plan
• D. Provide education about healthy eating habits

Correct answer: C

Rationale: In this scenario, the priority intervention for the nurse is to initiate a structured eating plan. Anorexia nervosa is a serious eating disorder characterized by severe food restriction, which can lead to malnutrition and severe weight loss. By starting a structured eating plan, the nurse can ensure the client receives the necessary nutrition to begin the process of weight restoration and recovery. Monitoring vital signs is essential, but without addressing the nutrition deficiency, vital signs may not improve significantly. Establishing a therapeutic relationship is crucial for long-term care but may not address the immediate risk of malnutrition. Providing education about healthy eating habits is important but may not be effective initially due to the severity of the client's condition.

5. When should a mother introduce solid foods to her infant? The mother of a 4-month-old baby girl asks the nurse when she should introduce solid foods to her infant. The mother states, 'My mother says I should put rice cereal in the baby’s bottle now.' The nurse should instruct the mother to introduce solid foods when her child exhibits which behavior?

• A. Stops rooting when hungry
• B. Opens mouth when food comes her way
• C. Awakens once for nighttime feedings
• D. Gives up a bottle for a cup

Correct answer: B

Rationale: The correct answer is 'B: Opens mouth when food comes her way.' Readiness for solid foods is indicated by the infant showing interest in food and being able to sit up with support. This behavior demonstrates the infant's readiness to start introducing solid foods in their diet. Choices A, C, and D are incorrect because stopping rooting when hungry, awakening once for nighttime feedings, and giving up a bottle for a cup are not indicators of readiness for solid foods in infants.

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