Nursing Elites

1. A child with croup has an increased PCO2, a decreased pH, and a normal HCO3 blood gas value. Which finding does the nurse report to the healthcare provider based on these data?

• A. Uncompensated metabolic alkalosis
• B. Uncompensated metabolic acidosis
• C. Uncompensated respiratory acidosis
• D. Uncompensated respiratory alkalosis

Correct answer: C

Rationale: The blood gas values indicate uncompensated respiratory acidosis. In respiratory acidosis, there is an increased PCO2, decreased pH, and a normal HCO3 level. This condition requires immediate attention to address the underlying respiratory problem causing the acidosis.

2. During a well-child visit, a nurse is assessing a three-year-old toddler. Which of the following manifestations should the nurse report to the provider?

• A. Blood pressure 90/50
• B. Respiratory rate 45/min
• C. Weight 14.5 kg or 32 lb
• D. Heart rate 110/min

Correct answer: B

Rationale: A respiratory rate of 45/min is above the expected reference range for a 3-year-old toddler and may indicate respiratory dysfunction or acute respiratory distress. It is essential for the nurse to report this finding promptly to the healthcare provider for further evaluation and intervention.

3. During the oliguric phase of acute kidney injury, what intervention should be included in the plan of care for a child?

• A. Administer a loop diuretic.
• B. Provide a low-sodium diet.
• C. Weigh the child weekly.
• D. Provide a high-protein diet.

Correct answer: A

Rationale: During the oliguric phase of acute kidney injury, the priority is managing fluid balance. Administering a loop diuretic is crucial to promote diuresis and reduce fluid retention, aiding in managing the condition effectively. Providing a low-sodium diet may be beneficial but is not the priority intervention during this phase. Weighing the child weekly is important for monitoring overall health but does not directly address the oliguric phase. Providing a high-protein diet is not typically recommended in acute kidney injury, especially during the oliguric phase, as it can put additional stress on the kidneys.

4. Which assessment data would cause suspicion that a 3-year-old child has Hirschsprung disease?

• A. Clay-colored stools and dark urine
• B. History of early passage of meconium in the newborn period
• C. History of chronic, progressive constipation and failure to gain weight
• D. Continual bouts of foul-smelling diarrhea

Correct answer: C

Rationale: Hirschsprung disease is characterized by chronic, progressive constipation and failure to gain weight. These symptoms are indicative of the disorder due to the absence of ganglion cells in the distal colon, leading to impaired motility and obstruction.

5. Which statement is not a principle of family-centered care?

• A. Respect family autonomy
• B. Provide flexible services
• C. Collaborate with family members
• D. Set strict rules for families to follow

Correct answer: D

Rationale: Family-centered care focuses on respecting family autonomy, providing flexible services, and collaborating with family members to ensure individualized care. Imposing strict rules contradicts the core principles of family-centered care, which prioritize partnership, communication, and shared decision-making between healthcare providers and families. Therefore, setting strict rules for families to follow goes against the collaborative and individualized nature of family-centered care, making it the statement that is not a principle of this approach.

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