Nursing Elites

1. A child with pyloric stenosis is having excessive vomiting. The nurse should assess for what potential complication?

• A. Hyperkalemia
• B. Hyperchloremia
• C. Metabolic acidosis
• D. Metabolic alkalosis

Correct answer: D

Rationale: Excessive vomiting in pyloric stenosis leads to the loss of stomach acid (hydrochloric acid), resulting in metabolic alkalosis, not hyperkalemia, hyperchloremia, or metabolic acidosis. Metabolic alkalosis is characterized by a higher pH level in the blood due to the loss of acid and a relative increase in bicarbonate. Hyperkalemia is an elevated level of potassium in the blood and is not directly related to excessive vomiting in pyloric stenosis. Hyperchloremia is an excess of chloride in the blood, which is not typically associated with this condition. Metabolic acidosis is a condition characterized by a lower pH level in the blood, caused by an excess of acid or a loss of bicarbonate, which is not the typical complication seen in pyloric stenosis with excessive vomiting.

2. What is a common significant side effect of opioid administration?

• A. Euphoria
• B. Diuresis
• C. Constipation
• D. Allergic reactions

Correct answer: C

Rationale: Constipation is one of the most common side effects of opioid administration due to the slowing down of gastrointestinal motility. Opioids affect the bowel movements, leading to constipation. Euphoria, while a possible effect, is less common than constipation. Diuresis is not a typical side effect of opioids; instead, urinary retention may occur. Allergic reactions are rare side effects of opioids, with symptoms such as rash, itching, or anaphylaxis.

3. Clinical manifestations of sodium excess (hypernatremia) include which signs or symptoms?

• A. Hyperreflexia
• B. Abdominal cramps
• C. Cardiac dysrhythmias
• D. Dry, sticky mucous membranes

Correct answer: D

Rationale: Hypernatremia often presents with dry, sticky mucous membranes due to dehydration. Hyperreflexia and abdominal cramps may also occur, but dry mucous membranes are more consistently observed in cases of sodium excess.

4. The nurse is planning an educational session for a group of 9-year-olds and their parents aimed at decreasing injuries and accidents among this age group. Which topics should be included in the educational session to accomplish the goal?

• A. Safety rules when dealing with fire to prevent burns.
• B. Safety rules when dealing with toxic substances to prevent poisonings.
• C. Pedestrian, motor vehicle, and bike safety rules.
• D. Safety information regarding the use of all-terrain vehicles (ATVs).

Correct answer: C

Rationale: For school-aged children, pedestrian, motor vehicle, and bike safety are critical areas to focus on as accidents involving these are common in this age group. Education about fire safety and toxic substances is also important, but the priority is on preventing accidents in everyday activities. Therefore, choices A, B, and D are not the most relevant for addressing the goal of decreasing injuries and accidents in this age group.

5. The parent asks when the soft area in the infant's head will go away. What is the best response by the nurse?

• A. The area is called the anterior fontanel (fontanelle) and typically closes anytime up to 18 months of age.
• B. The area is called a fontanel (fontanelle). They remain open to allow for rapid brain growth in the first months of life.
• C. The soft spots may stay open until your infant is 2 or 3 years old.
• D. Soft spots on the infant's head should have closed by now.

Correct answer: A

Rationale: The best response by the nurse is A, as the anterior fontanel typically closes between 12-18 months of age, allowing for brain growth during infancy. Choice B is incorrect because it does not provide a specific timeframe for the closure of the fontanel. Choice C is incorrect as it suggests a later closure timeframe than usual. Choice D is incorrect as it states that the soft spots should have closed already, which is inaccurate for a 6-month-old infant.

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