Nursing Elites

1. A 2-year-old child is brought to the health care provider's office with a chief complaint of mild diarrhea for 2 days. Nutritional counseling by the nurse should include which statement?

• A. Place the child on clear liquids and gelatin for 24 hours
• B. Continue with the regular diet and include oral rehydration fluids
• C. Give bananas, apples, rice, and toast as tolerated
• D. Place NPO for 24 hours, then rehydrate with milk and water

Correct answer: B

Rationale: In managing mild diarrhea in a 2-year-old child, it is important to maintain their regular diet and include oral rehydration fluids. Choice A of placing the child on clear liquids and gelatin for 24 hours may not provide adequate nutrition and can lead to further electrolyte imbalances. Choice C of giving bananas, apples, rice, and toast as tolerated is a part of the BRAT diet, which is not recommended as the primary approach anymore due to its limited nutritional value. Choice D of placing the child NPO for 24 hours and then rehydrating with milk and water is not appropriate as it can worsen dehydration and delay recovery. Therefore, the best option is to continue the child's regular diet while incorporating oral rehydration fluids to prevent dehydration and maintain nutritional status.

2. A nurse is providing teaching to a newly licensed nurse about the care of a client who has MRSA. Which of the following statements by the newly licensed nurse indicates an understanding of teaching?

• A. I will place the client in a private room
• B. I will tell the client’s visitors to wear a mask when they are within 3 feet of the client
• C. I will remove my gown after leaving the client’s room
• D. I will wear an N95 respirator mask when caring for the client

Correct answer: A

Rationale: The correct answer is A: 'I will place the client in a private room.' Placing the client in a private room helps prevent the spread of MRSA, a contact precaution. Choice B is incorrect because visitors should be following standard precautions for MRSA, not just wearing a mask within a specific distance. Choice C is incorrect as the gown should be removed before exiting the client's room to prevent the spread of MRSA. Choice D is incorrect as an N95 respirator mask is not typically required for the care of a client with MRSA; standard precautions are usually sufficient.

3. A 15-year-old client has been placed in a Milwaukee Brace. Which statement from the adolescent indicates the need for additional teaching?

• A. I will only have to wear this for 6 months.
• B. I should inspect my skin daily.
• C. The brace will be worn day and night.
• D. I can take it off when I shower.

Correct answer: A

Rationale: The correct answer is A. The statement 'I will only have to wear this for 6 months' indicates a need for additional teaching because the Milwaukee Brace is typically worn for 12-18 months, not just 6 months. Choice B is correct as inspecting the skin daily is important to prevent skin breakdown. Choice C is correct as the brace is usually worn day and night for effectiveness. Choice D is correct as the brace can be removed when showering to maintain hygiene.

4. Twenty minutes after starting a heat application, the client mentions that the heating pad no longer feels warm enough. What is the best response by the LPN/LVN?

• A. That indicates you have derived the maximum benefit, and the heat can be removed.
• B. Your blood vessels are dilating and removing the heat from the site.
• C. We will increase the temperature by 5 degrees when the pad no longer feels warm.
• D. The body's receptors adapt over time as they are exposed to heat.

Correct answer: D

Rationale: Choice D is the correct response. The body's receptors adapt to the heat over time, which can explain why the client no longer perceives the warmth from the heating pad. This phenomenon is known as thermal adaptation. Choices A, B, and C are incorrect. Choice A is inaccurate because the client not feeling the warmth does not necessarily mean they have derived the maximum benefit. Choice B incorrectly states that blood vessels dilating remove heat, which is not accurate. Choice C suggests increasing the temperature when the pad no longer feels warm, which could potentially lead to burns or discomfort for the client.

5. A client requires rectal temperature monitoring, and a nurse has a thermometer with a long, slender tip at the bedside. What is the appropriate action for the nurse to take?

• A. Obtain a thermometer with a short, blunt insertion end
• B. Use the available thermometer as is
• C. Request a new thermometer
• D. Measure the temperature orally instead

Correct answer: A

Rationale: When monitoring rectal temperature, it is crucial to use a thermometer with a short, blunt insertion end to prevent injury and ensure accurate readings. Using a thermometer with a long, slender tip can pose a risk of perforation or discomfort for the client. Therefore, the appropriate action for the nurse to take is to obtain a thermometer with a short, blunt insertion end. Using the available thermometer as is would not address the safety concerns. Requesting a new thermometer is unnecessary when a suitable one is available by just obtaining it. Measuring the temperature orally instead would not provide the required rectal temperature monitoring.

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