Nursing Elites

1. When preparing an adolescent for a lumbar puncture, which of the following actions should the nurse take?

• A. Place a cardiac monitor on the adolescent prior to the procedure
• B. Apply topical analgesic cream to the site one hour prior to the procedure
• C. Keep the adolescent in a semi-Fowler's position for 4 hours following the procedure
• D. Restrict fluids for 2 hours following the procedure

Correct answer: B

Rationale: The correct action for the nurse when preparing an adolescent for a lumbar puncture is to apply topical analgesic cream to the site one hour before the procedure. This helps reduce pain experienced during the lumbar puncture, making the procedure more comfortable for the adolescent. Placing a cardiac monitor on the adolescent is not necessary for a lumbar puncture. Keeping the adolescent in a semi-Fowler's position for 4 hours following the procedure is not a standard practice after a lumbar puncture. Restricting fluids for 2 hours following the procedure is not a requirement for a lumbar puncture preparation.

2. A healthcare provider is planning care for a child with hyperkalemia. Which manifestation associated with the documented hyperkalemia requires immediate intervention by the healthcare provider?

• A. Hyperthermia
• B. Respiratory distress
• C. Seizures
• D. Cardiac arrhythmias

Correct answer: D

Rationale: In hyperkalemia, cardiac arrhythmias are the most critical and life-threatening manifestation that requires immediate intervention. Hyperkalemia can lead to dangerous heart rhythm disturbances, potentially resulting in cardiac arrest. Prompt treatment is essential to stabilize the heart rhythm and prevent life-threatening complications. Hyperthermia, respiratory distress, and seizures are not typically associated with hyperkalemia and should be addressed, but cardiac arrhythmias pose the most urgent risk to the patient's life.

3. A newborn diagnosed with an omphalocele defect is admitted to the intensive care nursery. Which nursing action is appropriate based on the current data?

• A. Placing the newborn on a radiant warmer
• B. Placing the newborn in an open crib
• C. Preparing the newborn for phototherapy
• D. Preparing the newborn for bottle-feeding

Correct answer: A

Rationale: Placing the newborn on a radiant warmer is appropriate as it helps maintain the body temperature and prevent hypothermia in a newborn with an omphalocele defect. This is crucial for the infant's well-being and supports their physiological stability.

4. The healthcare professional is completing the intake and output record for a child admitted for fluid volume deficit. The child has had the following intake and output during the shift: 4 oz of Pedialyte, One-half of an 8-oz cup of clear orange Jell-O, Two graham crackers, 200 mL of D5 1/2 sodium chloride IV. Output: 345 mL of urine, 50 mL of loose stool. How many milliliters should the healthcare professional document as the client's total intake? Give the numerical answer only. Do not include any units of measurement.

• A. 440
• B. 400
• C. 410
• D. 450

Correct answer: A

Rationale: The total intake is 440 mL (4 oz of Pedialyte = 120 mL, half of an 8 oz cup of Jell-O = 120 mL, and 200 mL of IV fluids). The graham crackers are not counted as intake. Therefore, the correct answer is 440. Choice B (400) is incorrect because it does not account for the intake of Jell-O. Choice C (410) is incorrect as it does not include the Pedialyte intake. Choice D (450) is incorrect because it overestimates the total intake by including the graham crackers.

5. A parent of a child with cerebral palsy is being taught about home care by a healthcare provider. Which statement by the parent indicates an understanding of the teaching?

• A. I will perform range-of-motion exercises twice a day.
• B. I will apply a heating pad on my child's legs to reduce spasms.
• C. I will allow my child to rest in a recliner for 1 hour each day.
• D. I will use wrist splints to maintain alignment.

Correct answer: D

Rationale: Using wrist splints can help maintain alignment and prevent contractures in a child with cerebral palsy. This intervention is crucial in managing the condition and supporting the child's mobility and function.

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