Nursing Elites

1. A healthcare provider is assessing an infant who has hydrocephalus and is 6 hours postoperative following placement of a ventriculoperitoneal shunt. Which of the following findings should the provider report to the healthcare provider?

• A. Decreased urine output
• B. Temperature of 37.5 degrees C (99.5 degrees F)
• C. Heart rate 130/min
• D. Leakage of cerebrospinal fluid

Correct answer: D

Rationale: The provider should report the leakage of cerebrospinal fluid to the healthcare provider as it may indicate shunt malfunction or infection, requiring immediate attention to prevent complications. Decreased urine output, a temperature of 37.5 degrees C, and a heart rate of 130/min are common postoperative findings and may not be directly related to shunt function. While these findings should still be monitored, they do not require immediate reporting like cerebrospinal fluid leakage.

2. A child is being assessed for possible appendicitis with perforation. Which of the following findings should the nurse expect?

• A. Hyperactive bowel sounds
• B. Abdominal distension
• C. Hypoactive bowel sounds
• D. Bradycardia

Correct answer: D

Rationale: In a child with appendicitis and possible perforation, the nurse should expect bradycardia due to peritoneal irritation. Bradycardia is a common response to peritoneal inflammation or infection, indicating a possible serious complication. Hyperactive bowel sounds, abdominal distension, and hypoactive bowel sounds are more commonly associated with other gastrointestinal conditions and are less likely to be present in a child with appendicitis and perforation. Therefore, the correct answer is bradycardia (D) as it aligns with the expected physiological response in this scenario.

3. A patient is receiving glucocorticoids for the treatment of rheumatoid arthritis. The patient complains of having a headache. Which ordered medication should the nurse administer?

• A. Aspirin
• B. Acetaminophen
• C. Ibuprofen
• D. Naproxen Sodium (Aleve)

Correct answer: B

Rationale: When a patient is already receiving glucocorticoids for rheumatoid arthritis and complains of a headache, it is essential to consider the potential interactions and side effects of additional medications. Aspirin and NSAIDs like ibuprofen and naproxen sodium can increase the risk of gastrointestinal irritation and ulceration when used concurrently with glucocorticoids. Acetaminophen is a safer choice in this scenario for managing the patient's headache without exacerbating the gastrointestinal issues associated with the use of glucocorticoids. Acetaminophen does not have the same gastrointestinal side effects as aspirin, ibuprofen, or naproxen sodium, making it the most appropriate option for headache relief in this case.

4. In caring for an adolescent with severe abdominal pain due to appendicitis, where should the nurse identify as McBurney's point?

• A. Right lower quadrant
• B. Left lower quadrant
• C. Right upper quadrant
• D. Left upper quadrant

Correct answer: A

Rationale: McBurney's point is located in the right lower quadrant of the abdomen, specifically between the umbilicus and the anterior iliac crest. This point is significant in diagnosing appendicitis, as tenderness at McBurney's point is a classic sign of appendicitis and indicates inflammation near the appendix. Therefore, the correct answer is the 'Right lower quadrant.' Choices B, C, and D are incorrect because McBurney's point is not located in the left lower quadrant, right upper quadrant, or left upper quadrant of the abdomen.

5. A child has Wilms' tumor and is scheduled for surgery. Which of the following actions should the nurse include in the plan of care?

• A. Palpate the child's abdomen daily for tumor size.
• B. Reposition the child frequently.
• C. Prepare the child for chemotherapy.
• D. Avoid palpating the abdomen.

Correct answer: D

Rationale: Palpating the abdomen of a child with Wilms' tumor should be avoided to prevent the risk of rupturing the tumor and spreading cancer cells. This action is crucial to maintain the child's safety and prevent potential complications before surgery.

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