Nursing Elites

1. A nurse is caring for an infant with intractable vomiting. For what complication is it most important for the nurse to assess?

• A. Acidosis
• B. Alkalosis
• C. Hyperkalemia
• D. Hypernatremia

Correct answer: B

Rationale: When an infant experiences intractable vomiting, it can lead to the loss of stomach acids, resulting in metabolic alkalosis. Alkalosis is characterized by elevated blood pH and can lead to serious complications. Assessing for alkalosis is essential in this scenario to monitor and manage the infant's condition. Choices A, C, and D are incorrect because in this context, the primary concern is the metabolic imbalance caused by excessive vomiting, leading to alkalosis rather than acidosis, hyperkalemia, or hypernatremia.

2. Why might a healthcare provider question a health care provider's order for a tap water enema for a 6-month-old infant with suspected Hirschsprung disease?

• A. The result could lead to loss of necessary nutrients.
• B. It could cause a fluid and electrolyte imbalance.
• C. It could increase the fear of intrusive procedures.
• D. The result could cause shock from a sudden drop in temperature.

Correct answer: B

Rationale: The correct answer is B. Tap water enemas can cause significant fluid and electrolyte imbalances, particularly in infants, making them unsafe for this age group. Choice A is incorrect because tap water enemas are unlikely to lead to loss of necessary nutrients. Choice C is incorrect as it does not directly relate to the physiological risk of tap water enemas. Choice D is incorrect as shock from a sudden drop in temperature is not a common concern with tap water enemas.

3. .A child with type 1 diabetes mellitus is being discharged from the hospital. What is important for the nurse to include in the discharge teaching?

• A. Monitor blood glucose levels once a day
• B. Follow a strict meal plan
• C. Administer insulin only when blood glucose is high
• D. Recognize signs of hypoglycemia

Correct answer: D

Rationale: Recognizing signs of hypoglycemia is crucial for managing type 1 diabetes mellitus and preventing complications.

4. An 18-month-old was brought to the emergency department by her mother, who states, 'I think she broke her arm.' The child is sent for a radiograph to confirm the fracture. Additional assessment of the child leads the nurse to suspect possible child abuse. Which type of fracture would the radiograph most likely reveal?

• A. Plastic deformity.
• B. Buckle fracture.
• C. Spiral fracture.
• D. Greenstick fracture.

Correct answer: C

Rationale: A spiral fracture is characterized by a twisting injury, often indicating child abuse due to the mechanism involved. This type of fracture is commonly seen in non-accidental trauma cases. Plastic deformity is not typically seen on radiographs but refers to a change in the shape of a bone without breaking. Buckle fractures are incomplete fractures commonly seen in children due to their softer bones. Greenstick fractures are also incomplete fractures, but they do not typically raise suspicion of child abuse as spiral fractures do.

5. The nurse is caring for a 3-day-old girl with Down syndrome whose mother had no prenatal care. What is the priority nursing diagnosis?

• A. Imbalanced nutrition, less than body requirements related to the effects of hypotonia
• B. Deficient knowledge related to the presence of a genetic disorder
• C. Delayed growth and development related to a cognitive impairment
• D. Impaired physical mobility related to poor muscle tone

Correct answer: A

Rationale: The priority nursing diagnosis for a 3-day-old girl with Down syndrome, whose mother had no prenatal care, is imbalanced nutrition, less than body requirements related to the effects of hypotonia. Newborns with Down syndrome often experience feeding difficulties due to hypotonia, which can lead to inadequate nutrition intake. Option B is incorrect because at this age, the infant is not capable of having knowledge deficits related to a genetic disorder. Option C is incorrect as delayed growth and development are not the immediate priority in this scenario. Option D is incorrect as impaired physical mobility is not typically a priority concern for a newborn with Down syndrome.

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