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. The mother of a 5-year-old boy with a myelomeningocele who has developed a sensitivity to latex is being taught by the nurse. Which response from his mother indicates a need for further teaching?

• A. He needs to wear a medical alert identification.
• B. I will need to inform his caregivers about this.
• C. A product's label always indicates if it is latex-free.
• D. He should avoid all contact with latex.

Correct answer: C

Rationale: Choice C indicates a need for further teaching because not all products are clearly labeled as latex-free. It is essential for the mother to understand that she should not solely rely on product labels to determine latex content. She should be encouraged to verify with manufacturers and consult healthcare providers for accurate information. Choices A, B, and D are correct responses. Wearing a medical alert identification, informing caregivers, and ensuring the boy avoids all contact with latex are crucial steps in managing his sensitivity to latex and preventing potential allergic reactions.

3. A child who had surgery for a congenital heart defect is being discharged. What is an important aspect of the discharge teaching?

• A. Teaching the parents about signs of infection
• B. Providing instructions on wound care
• C. Scheduling follow-up appointments
• D. Explaining the use of prescribed medications

Correct answer: D

Rationale: Explaining the use of prescribed medications is crucial as it helps ensure the proper management of the child's condition post-discharge. Understanding how and when to administer medications is essential for the child's recovery. While teaching the parents about signs of infection, providing wound care instructions, and scheduling follow-up appointments are also important aspects of care, ensuring the correct use of prescribed medications takes precedence to prevent complications and promote the child's well-being.

4. At 0345, you receive a call for a woman in labor. Upon arriving at the scene, you are greeted by a very anxious man who tells you that his wife is having her baby 'now.' This man escorts you into the living room where a 25-year-old woman is lying on the couch in obvious pain. After determining that delivery is not imminent, you begin transport. While en route, the mother tells you that she feels the urge to push. You assess her and see the top of the baby's head bulging from the vagina. What is your most appropriate first action?

• A. allow the head to deliver and check for the location of the cord
• B. advise your partner to stop the ambulance and assist with the delivery
• C. tell the mother to take short, quick breaths until you arrive at the hospital
• D. prepare the mother for an emergency delivery and open the obstetrics kit

Correct answer: B

Rationale: The correct action in this scenario is to advise your partner to stop the ambulance and assist with the delivery. When the mother feels the urge to push and you see the baby's head bulging from the vagina, it indicates an imminent delivery. Stopping the ambulance allows for a safer environment for the delivery of the baby and ensures that immediate assistance can be provided to both the mother and the newborn. Allowing the head to deliver before checking for the cord (Choice A) may delay necessary interventions in case of complications. Instructing the mother to take short, quick breaths (Choice C) is not appropriate when the baby's head is already visible. Preparing for an emergency delivery and opening the obstetrics kit (Choice D) is important but should come after stopping the ambulance and assisting with the imminent birth.

5. What are the most common signs and symptoms of leukemia related to bone marrow involvement?

• A. petechiae, infection, fatigue
• B. headache, papilledema, irritability
• C. muscle wasting, weight loss, fatigue
• D. decreased intracranial pressure, psychosis, confusion

Correct answer: A

Rationale: The correct answer is A: petechiae, infection, fatigue. In leukemia, bone marrow involvement leads to a decrease in normal blood cell production, resulting in petechiae (small red or purple spots on the skin), increased susceptibility to infections due to decreased white blood cells, and fatigue from anemia. Choices B, C, and D are incorrect because they do not directly relate to the typical signs and symptoms of leukemia with bone marrow involvement. Headache, papilledema, irritability, muscle wasting, weight loss, decreased intracranial pressure, psychosis, and confusion are not typically associated with leukemia and bone marrow involvement.

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