Nursing Elites

1. A school-age child is 2 hours postoperative following a tonsillectomy. Which of the following actions should the nurse include in the plan of care?

• A. Place a heating pad at the surgical site.
• B. Encourage the child to cough every 2 hours.
• C. Administer analgesics to the child on a regular schedule.
• D. Apply an ice collar to the child's neck.

Correct answer: D

Rationale: After a tonsillectomy, applying an ice collar to the child's neck helps decrease pain and swelling. Heat should be avoided as it can increase bleeding. Encouraging coughing may increase the risk of bleeding. Administering analgesics on a regular schedule is essential for pain management, but the immediate postoperative period may require additional interventions like ice collar application.

2. The healthcare provider is planning care for a patient receiving morphine sulfate via a patient-controlled analgesia pump. Which intervention may be required due to a potential adverse effect of this drug?

• A. Administering a cough suppressant
• B. Inserting a Foley catheter
• C. Administering an anti-diarrheal
• D. Monitoring urinary output

Correct answer: B

Rationale: Morphine can lead to urinary retention and urinary hesitancy. If a patient shows signs of bladder distention or inability to void, the healthcare provider should be notified, and urinary catheterization may be necessary. Administering a cough suppressant or an anti-diarrheal is not typically required to address adverse effects of morphine. Liver function tests (LFTs) are not directly related to the potential adverse effects of morphine on the urinary system.

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. A nasogastric tube for suction is ordered for a neonate diagnosed with a diaphragmatic hernia. Which complication related to gastric drainage is the priority when planning care for this neonate?

• A. Weight loss
• B. Metabolic alkalosis
• C. Dehydration
• D. Hyperbilirubinemia

Correct answer: B

Rationale: Metabolic alkalosis is the priority complication to consider when a neonate with a diaphragmatic hernia is placed on gastric suction. Prolonged gastric drainage can lead to the loss of stomach acids, resulting in metabolic alkalosis, which can have serious consequences for the neonate's health.

5. What does a Z-score of -3.00 indicate?

• A. The child's score indicates he is ahead of his peers and performing well
• B. The child's score places him within normal limits on this test item
• C. The test is inconclusive
• D. The child's score falls below the majority of his peers on this test

Correct answer: D

Rationale: A Z-score of -3.00 indicates that the child's performance is significantly below the average of their peers. It represents an extreme low score, indicating a substantial deviation from the mean performance of the group.

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