Nursing Elites

1. During an assessment, an infant is suspected to have intussusception. Which of the following findings should the nurse expect?

• A. Currant jelly stools
• B. Projectile vomiting
• C. Scaphoid abdomen
• D. Frequent stools

Correct answer: A

Rationale: Intussusception is a condition where one segment of the intestine telescopes into another, causing obstruction. The classic presentation includes currant jelly stools, which are a mixture of blood and mucus due to the sloughing of the intestinal mucosa. This finding is a result of the compromised blood supply to the affected area and is a key characteristic associated with intussusception.

2. The healthcare provider is caring for a child on bed rest who has severe edema in the left lower extremity due to blocked lymphatic drainage. Which nursing diagnosis would take priority?

• A. Risk for Impaired Skin Integrity
• B. Risk for Altered Body Image
• C. Risk for Imbalanced Nutrition: Less Than Body Requirements
• D. Risk for Activity Intolerance

Correct answer: A

Rationale: The priority nursing diagnosis in this scenario is 'Risk for Impaired Skin Integrity' because severe edema in the left lower extremity can lead to compromised circulation and pressure ulcers, increasing the risk of skin breakdown and infection. Addressing and preventing impaired skin integrity is crucial for the child's overall health and well-being.

3. The 6-year-old child scheduled for an orchiopexy shyly asks the nurse, 'What are they going to do to me 'down there'? What is the nurse's best response?

• A. They are going to fix you up 'down there'.
• B. They will move your testicle from your abdomen to your scrotum.
• C. What do you think your doctor is going to do?
• D. You shouldn't worry. Your doctor knows exactly what to do.

Correct answer: C

Rationale: The nurse should encourage the child to express his thoughts and feelings about the upcoming surgery. This approach helps the child feel heard and understood while providing an opportunity to address any misconceptions or fears. By asking the child what he thinks the doctor will do, the nurse engages the child in a conversation that can help alleviate anxiety and build trust. School-age children often have fears related to bodily harm, and open communication can help alleviate such concerns. Choices A and D do not encourage open communication or address the child's concerns directly. Choice B provides too much detail that may overwhelm the child and is not age-appropriate for a 6-year-old.

4. A toddler is admitted to the surgical unit for a planned closure of a temporary colostomy. Which medical prescription should the nurse question?

• A. Clear liquids today, NPO tomorrow
• B. Type and cross-match for 1 unit of packed red blood cells
• C. Rectal temperatures every 4 hours
• D. Start an intravenous line with D5NS at 20 mL per hour

Correct answer: C

Rationale: The correct answer is C. Rectal temperatures should be avoided in a toddler with a colostomy due to the risk of injury. Choices A, B, and D are appropriate medical prescriptions for a toddler undergoing colostomy closure. Choice A ensures the toddler's intake of clear liquids before being made NPO, choice B prepares for possible blood transfusion needs, and choice D initiates intravenous hydration with D5NS at an appropriate rate.

5. What is the most appropriate nursing consideration for a patient who is prescribed verapamil and digoxin?

• A. Restrict intake of oral fluids and high-fiber foods
• B. Take an apical pulse for 30 seconds before administration
• C. Notify the healthcare provider of nausea, vomiting, and visual changes
• D. Hold the medications if the heart rate is greater than 110 bpm

Correct answer: C

Rationale: When a patient is prescribed verapamil and digoxin, it is crucial to monitor for signs of digoxin toxicity due to the potential interaction between these medications. Verapamil can elevate digoxin blood serum levels, increasing the risk of toxicity. Symptoms of digoxin toxicity include nausea, vomiting, and visual changes. Therefore, the most appropriate nursing consideration is to notify the healthcare provider of these symptoms. Restricting intake of oral fluids and high-fiber foods is not a specific consideration related to this medication combination. Before administering digoxin, it is essential to take an apical pulse for a full minute, not just 30 seconds, to ensure accuracy. Additionally, holding the medications if the heart rate exceeds 110 bpm is not a typical response to the combination of verapamil and digoxin, which can cause bradycardia rather than tachycardia.

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