Nursing Elites

1. A 4-year-old child is admitted to the hospital secondary to dehydration. Laboratory tests indicate a high hemoglobin and hematocrit, and the serum sodium is below normal levels. Which condition does the nurse suspect based on the current data?

• A. Hypernatremia
• B. Metabolic acidosis
• C. Hypotonic dehydration
• D. Isotonic dehydration

Correct answer: C

Rationale: The correct answer is hypotonic dehydration. The combination of high hemoglobin and hematocrit with low serum sodium indicates hypotonic dehydration. In this condition, there is an excess of solutes relative to water, leading to higher red blood cell concentration (elevated hemoglobin and hematocrit) and low serum sodium levels.

2. A nurse is planning care for a 2-month-old infant who is postoperative following surgical repair of a cleft lip. Which of the following actions should the nurse take?

• A. Position the infant on his abdomen
• B. Cleanse the incision site with hydrogen peroxide
• C. Offer the infant a pacifier
• D. Keep the infant's elbow restrained

Correct answer: D

Rationale:

3. The healthcare professional is completing the intake and output record for a child admitted for fluid volume deficit. The child has had the following intake and output during the shift: 4 oz of Pedialyte, One-half of an 8-oz cup of clear orange Jell-O, Two graham crackers, 200 mL of D5 1/2 sodium chloride IV. Output: 345 mL of urine, 50 mL of loose stool. How many milliliters should the healthcare professional document as the client's total intake? Give the numerical answer only. Do not include any units of measurement.

• A. 440
• B. 400
• C. 410
• D. 450

Correct answer: A

Rationale: The total intake is 440 mL (4 oz of Pedialyte = 120 mL, half of an 8 oz cup of Jell-O = 120 mL, and 200 mL of IV fluids). The graham crackers are not counted as intake. Therefore, the correct answer is 440. Choice B (400) is incorrect because it does not account for the intake of Jell-O. Choice C (410) is incorrect as it does not include the Pedialyte intake. Choice D (450) is incorrect because it overestimates the total intake by including the graham crackers.

4. Which standardized test would be most appropriate for assessing the motor development of a 2-month-old infant in a high-risk clinic?

• A. Peabody Developmental Motor Scale (PDMS-2)
• B. Bruininks-Oseretsky Test of Motor Proficiency (BOT-2)
• C. Pediatric Evaluation of Disability Index (PEDI)
• D. School Assessment of Motor and Process Skills (School-AMPS)

Correct answer: A

Rationale: The Peabody Developmental Motor Scale (PDMS-2) is specifically designed to assess the motor development of infants and young children, making it the most appropriate choice for evaluating a 2-month-old infant in a high-risk clinic setting.

5. The nurse is teaching a patient with cancer about a new prescription for a fentanyl patch, 25mcg/hr. for chronic back pain. Which statement is the most appropriate to include in the teaching plan.

• A. You will need to change this patch every day, regardless of your pain level.
• B. This type of pain medication is not as likely to cause breathing problems.
• C. With the first patch, it will take about 24hrs before you feel the full effects.
• D.

Correct answer: C

Rationale: Full analgesic effects can take up to 24 hours to develop with fentanyl patches. Most patches are changed every 72 hours. Has the same adverse effects as other opioids, including respiratory depression. Should avoid exposing the patch to external heat sources, because this may increase toxicity.

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