Nursing Elites

1. A 7-year-old child with sickle cell anemia presents to the emergency department with severe pain in the arms and legs. What is the nurse’s priority action?

• A. Administer prescribed pain medication
• B. Apply warm compresses to the affected areas
• C. Encourage the child to drink fluids
• D. Monitor the child’s oxygen saturation

Correct answer: A

Rationale: In a sickle cell crisis, pain management is a priority due to the severe pain experienced by the child. Administering prescribed pain medication is crucial to alleviate the pain and provide comfort to the child. Once pain is controlled, other comfort measures like applying warm compresses and encouraging fluid intake can be implemented. Monitoring oxygen saturation is important but not the priority action when dealing with severe pain in a sickle cell crisis.

2. A 10-year-old child is admitted to the hospital with a diagnosis of acute glomerulonephritis. The nurse notes that the child has edema and elevated blood pressure. What is the nurse’s priority action?

• A. Administer antihypertensive medication as prescribed
• B. Monitor the child’s urine output
• C. Elevate the child’s legs to reduce edema
• D. Restrict the child’s fluid intake

Correct answer: A

Rationale: In a child with acute glomerulonephritis presenting with edema and elevated blood pressure, the priority action for the nurse is to administer antihypertensive medication as prescribed. Managing blood pressure is essential to prevent further complications associated with the condition, such as worsening kidney function and cardiovascular strain. Monitoring urine output is important but not the priority over managing elevated blood pressure. Elevating the child's legs may help with edema but addressing the elevated blood pressure takes precedence. Fluid intake restriction may be necessary in some cases, but it is not the immediate priority when managing acute glomerulonephritis with edema and hypertension.

3. A child with pertussis is receiving azithromycin (Zithromax Injection) IV. Which intervention is most important for the nurse to include in the child's plan of care?

• A. Obtain vital signs to monitor for fluid overload
• B. Change IV site dressing every 3 days and as needed
• C. Monitor for signs of facial swelling or urticaria
• D. Assess for abdominal pain and vomiting

Correct answer: C

Rationale: When administering azithromycin IV, monitoring for signs of an allergic reaction, such as facial swelling or urticaria, is crucial. This helps in early detection of potential adverse reactions and ensures prompt intervention to prevent complications associated with the medication. The other options are not directly related to the administration of azithromycin IV in this scenario. Monitoring for fluid overload would be more relevant for fluid administration, changing IV site dressing is important but not the priority in this case, and assessing for abdominal pain and vomiting may be important but not as critical as monitoring for signs of an allergic reaction.

4. An adolescent’s mother calls the primary HCP’s office to inquire about the results of her daughter’s serum test that was drawn last week. Since it is the teenager’s 18th birthday, how should the nurse respond to this mother’s inquiry?

• A. Ask when the adolescent was last seen in the clinic
• B. Tell the mother to have the teenager call the clinic
• C. Since the serum sample was drawn last week, provide the mother with the findings
• D. Explain that the information cannot be released without the 18-year-old's permission

Correct answer: D

Rationale: When an individual turns 18, they are considered a legal adult and have the right to privacy regarding their medical information. Therefore, the nurse should explain to the mother that without the 18-year-old's permission, the results cannot be disclosed.

5. The healthcare provider is evaluating the effects of thyroid therapy used to treat a 5-month-old with hypothyroidism. Which behavior indicates that the treatment has been effective?

• A. Laughs readily, turns from back to side.
• B. Has strong Moro and tonic neck reflexes.
• C. Keeps fists clenched, opens hands when grasping an object.
• D. Can lift head, but not chest when lying on abdomen.

Correct answer: A

Rationale: The ability to laugh readily and turn from back to side indicates the effectiveness of thyroid therapy and normal development in a 5-month-old. These behaviors suggest improved muscle tone and motor skills, which are positive outcomes of thyroid hormone replacement therapy for hypothyroidism. Choices B, C, and D describe developmental milestones that are not specific indicators of the effectiveness of thyroid therapy in treating hypothyroidism in a 5-month-old.

Similar Questions