Nursing Elites

1. A 5-week-old infant with hypertrophic pyloric stenosis has developed projectile vomiting over the last two weeks. Which intervention should the nurse plan to implement?

• A. Instruct the mother to give sugar water only.
• B. Offer the infant oral rehydration every 2 hours.
• C. Provide Pedialyte feedings via nasogastric tube.
• D. Maintain intravenous fluid therapy.

Correct answer: D

Rationale: The correct intervention for a 5-week-old infant with hypertrophic pyloric stenosis presenting with projectile vomiting is to maintain intravenous fluid therapy. This is essential to maintain hydration before surgery. Instructing the mother to give sugar water only (Choice A) is inadequate and does not address the need for proper hydration. Offering oral rehydration every 2 hours (Choice B) may not be effective in cases of severe vomiting and could lead to further fluid loss. Providing Pedialyte feedings via nasogastric tube (Choice C) is an option, but in severe cases, intravenous fluid therapy is more effective in ensuring hydration and electrolyte balance.

2. The nurse is feeding an older adult who was admitted with aspiration pneumonia. The client is weak and begins coughing while attempting to drink through a straw. Which intervention should the nurse implement?

• A. Encourage the client to drink more slowly
• B. Stop feeding and assess for signs of aspiration
• C. Elevate the head of the bed further
• D. Teach coughing and deep breathing exercises

Correct answer: B

Rationale: When an older adult with aspiration pneumonia coughs while attempting to drink, it may indicate aspiration. Aspiration can lead to serious complications. Therefore, the appropriate intervention for the nurse in this situation is to stop feeding immediately and assess the client for signs of aspiration. Encouraging the client to drink more slowly (Choice A) may not address the risk of aspiration. Elevating the head of the bed further (Choice C) is generally beneficial to prevent aspiration but is not the priority when immediate assessment is needed. Teaching coughing and deep breathing exercises (Choice D) is not appropriate when the client is actively coughing during feeding and requires immediate assessment for potential aspiration.

3. A client reports dizziness when standing up quickly. What advice should the nurse give?

• A. Encourage the client to drink more fluids.
• B. Change positions slowly to prevent dizziness.
• C. Report the symptom to the healthcare provider immediately.
• D. Limit physical activity to avoid triggering dizziness.

Correct answer: B

Rationale: The correct advice for a client experiencing dizziness when standing up quickly is to change positions slowly to prevent dizziness. This symptom is suggestive of postural hypotension, where a sudden change in position can lead to a drop in blood pressure, causing dizziness. Encouraging the client to drink more fluids (Choice A) may be beneficial for other conditions but is not directly related to the prevention of dizziness in this case. Reporting the symptom to the healthcare provider immediately (Choice C) is important if the dizziness is persistent or severe, but the immediate action to prevent it is to change positions slowly. Limiting physical activity (Choice D) may not necessarily address the underlying cause of dizziness in this context.

4. A client with pancreatitis reports severe pain after eating fatty foods. What intervention should the nurse implement?

• A. Encourage the client to eat small, low-fat meals.
• B. Administer antispasmodic medication as prescribed.
• C. Instruct the client to avoid eating until the pain subsides.
• D. Increase the client’s intake of high-protein foods.

Correct answer: B

Rationale: In pancreatitis, pain after consuming fatty foods is common due to increased pancreatic stimulation. Administering antispasmodics is the appropriate intervention as it can help reduce the pain by decreasing pancreatic enzyme secretion. Encouraging the client to eat small, low-fat meals (Choice A) is beneficial in managing pancreatitis symptoms but does not directly address the acute pain. Instructing the client to avoid eating until the pain subsides (Choice C) may lead to nutritional deficiencies and is not the best approach. Increasing high-protein foods intake (Choice D) is not recommended as it can put additional strain on the pancreas.

5. A client with multiple sclerosis is admitted with an acute exacerbation. What is the nurse's priority action?

• A. Monitor the client’s vital signs every hour.
• B. Assess for changes in the client’s muscle strength.
• C. Administer prescribed corticosteroids to reduce inflammation.
• D. Educate the client on managing fatigue and preventing relapses.

Correct answer: C

Rationale: The correct answer is C. Administering prescribed corticosteroids to reduce inflammation is the priority action when a client with multiple sclerosis is admitted with an acute exacerbation. Corticosteroids help manage symptoms during exacerbations and reduce inflammation. Monitoring vital signs and assessing muscle strength are important aspects of care but not the priority during an acute exacerbation. Educating the client on managing fatigue and preventing relapses is essential but can be addressed after the acute exacerbation has been managed.

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