Nursing Elites

1. When assessing a child with suspected bacterial meningitis, what clinical manifestation is the nurse likely to observe?

• A. Photophobia
• B. High fever
• C. Rash
• D. Nasal congestion

Correct answer: B

Rationale: The correct answer is B: High fever. In bacterial meningitis, a high fever is a common clinical manifestation due to the body's inflammatory response to the infection. While photophobia (choice A) is also a common symptom in meningitis, it is not as specific as a high fever. Rash (choice C) is more commonly associated with viral infections or other conditions, rather than bacterial meningitis. Nasal congestion (choice D) is not a typical clinical manifestation of bacterial meningitis and is more commonly seen in respiratory infections. Therefore, when assessing a child with suspected bacterial meningitis, the nurse is most likely to observe a high fever as a key clinical manifestation.

2. A child with sickle cell anemia develops severe chest pain, fever, a cough, and dyspnea. What should the nurse do first?

• A. Administer 100% oxygen to relieve hypoxia
• B. Administer pain medication to relieve symptoms
• C. Notify the practitioner because chest syndrome is suspected
• D. Notify the practitioner because the child may be having a stroke

Correct answer: C

Rationale: The correct action to take first when a child with sickle cell anemia presents with severe chest pain, fever, cough, and dyspnea is to notify the practitioner because acute chest syndrome is suspected. This condition is a medical emergency requiring prompt intervention. Administering oxygen or pain medication may be necessary interventions but should not precede notifying the practitioner. Stroke is not typically associated with these symptoms in sickle cell anemia.

3. An infant who had cardiac surgery for a congenital defect is to be discharged. What should the nurse emphasize to the parents regarding administering the prescribed antibiotic?

• A. Give the antibiotic between feedings.
• B. Ensure that the antibiotic is administered as prescribed.
• C. Shake the bottle thoroughly before giving the antibiotic.
• D. Keep the antibiotic in the refrigerator after the bottle has been opened.

Correct answer: B

Rationale: The correct answer is B: 'Ensure that the antibiotic is administered as prescribed.' It is crucial for the parents to follow the prescribed antibiotic regimen to prevent infections and promote proper healing following cardiac surgery. Option A is incorrect because the timing of antibiotic administration may vary depending on the specific medication and instructions. Option C is not necessary and could potentially affect the antibiotic's effectiveness. Option D is not relevant to the administration of the antibiotic and does not ensure proper usage.

4. An order is written for an isotonic enema for a 2-year-old child. What is the maximum amount of fluid the nurse should administer without a specific order from the healthcare provider?

• A. 100 to 150 mL
• B. 155 to 250 mL
• C. 255 to 360 mL
• D. 365 to 500 mL

Correct answer: B

Rationale: For a 2-year-old child, the maximum recommended amount of fluid for an isotonic enema is between 155 to 250 mL. This range is considered safe to prevent overdistension and potential harm to the child's rectum. Choices A, C, and D exceed the safe range for a 2-year-old child and can lead to complications such as bowel perforation or electrolyte imbalances.

5. A child with a diagnosis of nephrotic syndrome is being discharged. What dietary instructions should the nurse provide?

• A. Encourage a high-protein diet
• B. Avoid foods high in salt
• C. Encourage a low-sodium diet
• D. Encourage a low-protein diet

Correct answer: B

Rationale: For a child with nephrotic syndrome, it is important to avoid foods high in salt. This instruction helps manage symptoms and prevent complications associated with the condition. High salt intake can lead to fluid retention and worsen edema, which are common issues in nephrotic syndrome. Encouraging a low-sodium diet is crucial to maintaining fluid balance and reducing strain on the kidneys. Choices A, C, and D are incorrect because a high-protein diet can further stress the kidneys, while a low-protein diet may not be necessary unless specifically advised by the healthcare provider. Encouraging a low-sodium diet is more appropriate for managing nephrotic syndrome.

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