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 2-year-old child is admitted with severe dehydration due to gastroenteritis. Which assessment finding indicates that the child's condition is improving?

• A. Decreased heart rate.
• B. Sunken fontanelle.
• C. Increased urine output.
• D. Dry mucous membranes.

Correct answer: C

Rationale: Increased urine output is a positive sign indicating that the child's hydration status is improving. It suggests that the kidneys are functioning more effectively and able to excrete urine, which is a crucial indicator of improved hydration levels in a dehydrated patient. Decreased heart rate (Choice A) can be a sign of possible shock. A sunken fontanelle (Choice B) is a sign of dehydration. Dry mucous membranes (Choice D) are also indicative of dehydration.

3. The mother of an 11-year-old boy with juvenile arthritis tells the nurse, 'I really don't want my son to become dependent on pain medication, so I only allow him to take it when he is really hurting.' Which information is most important for the nurse to provide this mother?

• A. The child should be encouraged to rest when experiencing pain
• B. Encourage quiet activities such as reading as a pain distracter
• C. The use of hot baths can be used as an alternative to pain medication
• D. Giving pain medication around the clock helps control the pain

Correct answer: D

Rationale: It is crucial for the nurse to educate the mother that giving pain medication around the clock helps manage pain effectively and improves the child's quality of life. This approach ensures a more consistent level of pain relief and prevents the pain from becoming severe, which can be more challenging to manage. Choices A, B, and C do not address the importance of consistent pain management and may not provide adequate relief for the child's condition.

4. A mother brings her 2-year-old son to the clinic because he has been crying and pulling on his earlobe for the past 12 hours. The child’s oral temperature is 101.2°F. Which intervention should the nurse implement?

• A. Ask the mother if the child has had a runny nose
• B. Cleanse purulent exudate from the affected ear canal
• C. Apply a topical antibiotic to the periauricle area
• D. Provide parent education to prevent recurrence

Correct answer: A

Rationale: In a child with ear pain and fever, asking about a runny nose is important to assess if the ear pain is associated with a respiratory infection, such as otitis media. This information can guide further assessment and treatment decisions. Choice B is incorrect because cleansing purulent exudate should be done by a healthcare provider, not the nurse. Choice C is incorrect as topical antibiotics should only be applied under healthcare provider's orders. Choice D is not the priority at this moment, as the immediate concern is assessing the association between the ear pain and a possible respiratory infection.

5. During a well-baby exam, a nurse finds that a 2-month-old's right testicle is not descended into the scrotum, but the left one is palpable. What should the nurse do?

• A. Ask if the right testis has been seen in the scrotum before
• B. Address potential concerns about future fertility
• C. Schedule an ultrasound to confirm the position of the testicle
• D. Prepare to obtain a urine specimen for culture

Correct answer: A

Rationale: The correct answer is to ask if the right testis has been seen in the scrotum before. The initial step in managing an undescended testicle is to determine if it has been previously observed in the scrotum or if this is a new finding. This information is crucial in deciding the next course of action. Choice B is incorrect because addressing future fertility concerns comes after confirming the status of the testicle. Choice C is unnecessary at this stage as the first step is to gather more history. Choice D is unrelated to the issue described and is not indicated in this scenario.

Similar Questions