Nursing Elites

1. A child with glomerulonephritis is admitted in the acute edematous phase. Based on this diagnosis, which nursing intervention should the nurse plan to include in the child's plan of care?

• A. Recommend parents bring favorite snacks
• B. Encourage ambulation daily to the playroom
• C. Measure blood pressure every 4 to 6 hours
• D. Offer a selection of fresh fruit for each meal

Correct answer: C

Rationale: The correct answer is to measure blood pressure every 4 to 6 hours. Monitoring blood pressure frequently is crucial in managing glomerulonephritis, as hypertension is a common complication during the acute edematous phase. Choice A is incorrect as it does not address the specific needs of a child with glomerulonephritis. Choice B is incorrect as excessive activity may not be suitable during the acute phase, as rest and monitoring are more important. Choice D is incorrect as the focus should be on monitoring vital signs rather than meal options.

2. Which intervention is most appropriate when caring for a patient experiencing a tonic-clonic seizure?

• A. Restrain the patient to prevent injury
• B. Place a tongue depressor in the patient's mouth
• C. Turn the patient to the side to maintain an open airway
• D. Attempt to stop the seizure by holding the patient’s arms

Correct answer: C

Rationale: During a tonic-clonic seizure, the priority is to ensure patient safety by maintaining an open airway to prevent aspiration. Turning the patient to the side helps achieve this goal by allowing any fluids to drain out of the mouth, reducing the risk of choking or aspiration. Restraint can lead to injury, placing a tongue depressor can cause harm or obstruct the airway further, and attempting to stop the seizure by holding the patient's arms is ineffective and can also result in injury. Therefore, the most appropriate intervention is to turn the patient to the side.

3. What is the most effective method to prevent medication errors during administration?

• A. Relying on memory for medication dosages
• B. Using a bar-code medication administration system
• C. Administering medications as quickly as possible to avoid delays
• D. Allowing another individual to administer medications

Correct answer: B

Rationale: Using a bar-code medication administration system is the best method to prevent medication errors during administration. This system verifies medication details electronically, ensuring that the correct medication is given to the right patient. Relying on memory for medication dosages (choice A) is not recommended as it can lead to errors. Administering medications quickly (choice C) may increase the risk of mistakes due to haste. Allowing another individual (choice D) to administer medications does not address the root cause of preventing errors during administration.

4. After admission, which observation is most important for the nurse to report immediately for an adult client who weighs 150 pounds and has partial-thickness and full-thickness burns over 40% of the body from a house fire?

• A. Poor appetite and refusal to eat
• B. Systolic blood pressure at 102
• C. Painful moaning and crying
• D. Urinary output of 20 ml/hr

Correct answer: D

Rationale: A urinary output of 20 ml/hr is a sign of inadequate kidney perfusion and could indicate hypovolemic shock, which requires immediate intervention. In this situation, with severe burns over a large portion of the body, monitoring urinary output is crucial to assess kidney function and fluid status. Poor appetite, systolic blood pressure at 102, and painful moaning and crying are important but do not indicate the immediate need for intervention like inadequate urinary output does.

5. A client confides to the nurse that the client has been substituting herbal supplements for high blood pressure instead of the prescribed medication. How should the nurse respond first?

• A. Ask the client's reason for choosing to take herbs instead of prescribed medication
• B. Reinforce that the healthcare provider prescribed the medication for a reason
• C. Have the client use their own words to describe complications of high blood pressure
• D. Point out the risks of not taking the prescribed medication rather than herbal supplements

Correct answer: A

Rationale: The correct answer is to ask the client's reason for choosing to take herbs instead of prescribed medication. Understanding the client's rationale for using herbal supplements allows the nurse to explore any misconceptions and provide education on the importance of the prescribed medication. Choice B is incorrect because simply reinforcing the prescription does not address the client's concerns or reasons for using herbal supplements. Choice C does not directly address the immediate concern of the client substituting medication with herbal supplements. Choice D focuses on the risks of not taking the prescribed medication rather than herbal supplements, which is not the most appropriate initial response.

Similar Questions