Nursing Elites

1. While auscultating the lungs of an adolescent with asthma, what should the nurse identify the sound as?

• A. Biots respiration
• B. Chaney-Stokes respiration
• C. Tachypnea
• D. Bradypnea

Correct answer: C

Rationale: The nurse should identify the sound heard during auscultation as tachypnea, which is characterized by a rapid, regular breathing pattern. In the case of an adolescent with asthma, tachypnea can be indicative of increased work of breathing due to airway constriction and inflammation. Biots respiration (choice A) is characterized by an irregular pattern of breathing with periods of apnea. Chaney-Stokes respiration (choice B) is a pattern of breathing characterized by alternating periods of deep, rapid breathing followed by periods of apnea. Bradypnea (choice D) refers to an abnormally slow breathing rate, which is not typically associated with asthma exacerbation.

2. When planning care for a pediatric client diagnosed with bacterial meningitis, what is the priority nursing diagnosis?

• A. Impaired Gas Exchange
• B. Risk for Infection
• C. Anxiety (parental)
• D. Acute Pain

Correct answer: A

Rationale: The priority nursing diagnosis when caring for a pediatric client with bacterial meningitis is 'Impaired Gas Exchange.' This diagnosis takes precedence due to the potential for respiratory complications associated with the condition. Bacterial meningitis can lead to increased intracranial pressure, compromising the child's ability to ventilate adequately. Therefore, monitoring and addressing any signs of respiratory distress are crucial in the care of these patients.

3. A child with suspected bacterial meningitis is under the care of a nurse. Which action should the nurse prioritize?

• A. Administer antibiotics as prescribed.
• B. Maintain the child on NPO status.
• C. Monitor the child's intake and output.
• D. Implement seizure precautions.

Correct answer: D

Rationale: The priority action for a child with suspected bacterial meningitis is to implement seizure precautions. Meningitis can lead to increased intracranial pressure, which may trigger seizures. By implementing seizure precautions, such as padding the side rails of the bed and ensuring a clear environment, the nurse aims to prevent injury during a potential seizure episode, prioritizing the child's safety. Administering antibiotics as prescribed is essential in treating bacterial meningitis, but seizure precautions take precedence due to the immediate risk of injury. Maintaining NPO status and monitoring intake and output are important aspects of care but are not the priority when considering the risk of seizures.

4. Which assessment finding would necessitate action by the nurse for a 10-month-old child who is 4 hours postoperative for the placement of a urethral stent?

• A. Bloody urine
• B. One void since returning from surgery
• C. Bladder spasms responding to pharmacologic intervention
• D. Double diapering from the previous shift

Correct answer: B

Rationale: In a postoperative scenario after the placement of a urethral stent, monitoring the child's voiding frequency is crucial. Having only one void since returning from surgery could indicate potential issues like urinary retention, which necessitates prompt nursing intervention to prevent complications.

5. Which urinalysis result should the nurse anticipate for a child admitted with acute glomerulonephritis?

• A. Bacteriuria and increased specific gravity
• B. Hematuria and proteinuria
• C. Proteinuria and decreased specific gravity
• D. Bacteriuria and hematuria

Correct answer: B

Rationale: In acute glomerulonephritis, the glomeruli become inflamed, leading to the leakage of red blood cells (hematuria) and proteins (proteinuria) into the urine. These are hallmark findings in this condition due to the damage to the glomerular filtration barrier. Bacteriuria, the presence of bacteria in the urine, is not typically associated with acute glomerulonephritis unless there is a concurrent urinary tract infection. Specific gravity may be normal or decreased due to the loss of proteins in the urine, rather than increased. Therefore, the correct anticipated urinalysis result for a child with acute glomerulonephritis is hematuria and proteinuria.

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