Nursing Elites

1. A 13-year-old client with type 1 diabetes is admitted to the hospital with a blood glucose level of 450 mg/dL. The client is lethargic and has fruity-smelling breath. What is the nurse’s priority action?

• A. Administer insulin as prescribed
• B. Start an IV infusion of normal saline
• C. Check the client’s urine for ketones
• D. Monitor the client’s vital signs

Correct answer: B

Rationale: The correct priority action for the nurse is to start an IV infusion of normal saline. The client's presentation with lethargy, fruity-smelling breath, and high blood glucose level indicates diabetic ketoacidosis (DKA). IV fluids are essential to correct dehydration and help stabilize the client's condition. Checking for ketones in the urine is important, but fluid replacement takes precedence to address the immediate risk of dehydration and electrolyte imbalances. Administering insulin is also a crucial intervention for DKA, but fluid resuscitation should first be initiated.

2. The parents of a 15-month-old boy tell the nurse that they are concerned because their son brings his spoon to his mouth but does not turn it over. What action should the nurse implement first?

• A. Discuss the possibility of a referral to a specialist
• B. Question the parents about their concern
• C. Advise the parents on proper spoon handling techniques for the child
• D. Recommend extending mealtimes to allow the child to finish eating

Correct answer: B

Rationale: The initial action for the nurse is to question the parents about their concerns. By doing so, the nurse can gather more information to understand the situation better. This helps in determining if the child's behavior is within normal development or if further action or referrals are necessary. Choice A is incorrect as it jumps to a specialist referral without fully assessing the situation first. Choice C is also incorrect because assuming the parents need advice on proper spoon handling techniques may not be the case. Choice D is incorrect as it does not address the core concern raised by the parents.

3. The nurse provides information about the human papillomavirus (HPV) vaccine to the mother of a 14-year-old adolescent who came to the clinic this morning complaining of menstrual cramping. Which explanation should the nurse provide to support administering the HPV vaccine to the adolescent at this visit?

• A. Use of protective barriers during sexual activity prevents most strains of HPV infection
• B. Most adolescents are not honest about being sexually active
• C. Not all strains of HPV will be covered if given at a later date
• D. Immunity must be established to prevent future HPV infection and the risk for cervical cancer

Correct answer: D

Rationale: Administering the HPV vaccine helps establish immunity before potential exposure to the virus, reducing the risk of HPV infection and subsequent development of cervical cancer. It is recommended to vaccinate adolescents before they become sexually active for maximum effectiveness. Choice A is incorrect because while protective barriers can reduce the risk, they do not prevent all strains of HPV. Choice B is incorrect and judgmental as it assumes dishonesty without providing relevant information about HPV vaccination. Choice C is incorrect as it downplays the importance of vaccination by suggesting that not all strains are necessary to cover, which is not the case in preventing HPV-related diseases.

4. During a well-baby check of a 7-month-old infant, the practical nurse notes an absence of babbling. Which focused assessment should the PN implement?

• A. Visual function.
• B. Auditory function.
• C. Cognitive function.
• D. Social development.

Correct answer: B

Rationale: The absence of babbling in a 7-month-old infant is a concerning auditory development milestone. Babbling is an early stage of language development that involves making various sounds. A lack of babbling could indicate a hearing impairment or other auditory issues. Therefore, the practical nurse should focus on assessing the infant's auditory function to determine if further evaluation or intervention is necessary. Choices A, C, and D are incorrect because the absence of babbling specifically points towards a potential issue related to auditory function rather than visual, cognitive, or social development.

5. A 2-year-old child with a history of frequent ear infections is brought to the clinic by the parents who are concerned about the child’s hearing. What should the nurse do first?

• A. Ask the parents about the child’s speech development
• B. Perform a hearing test
• C. Inspect the child’s ears for drainage
• D. Refer the child to an audiologist

Correct answer: C

Rationale: The most appropriate initial action for the nurse to take is to inspect the child's ears for drainage. This step can provide immediate information on the presence of infection or fluid, which could be impacting the child's hearing. By assessing for drainage, the nurse can gather valuable initial data to determine the next course of action, such as further evaluation or treatment. Asking about speech development or referring to an audiologist would be secondary steps after assessing the physical condition of the ears. Performing a hearing test would also be premature without first examining the ears for any visible issues.

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