Nursing Elites

1. A nurse is talking with an adolescent who is having difficulty dealing with several issues. Which of the following issues should the nurse identify as the priority?

• A. “I kind of like this boy in my class, but he doesn’t like me back.”
• B. “I want to hang out with the kids in the science club, but the jocks pick on them.”
• C. “I am so fat, I skip meals to try to lose weight.”
• D. “My dad wants me to be a lawyer like him, but I just want to dance.”

Correct answer: C

Rationale: The correct answer is C. Skipping meals to lose weight may indicate an eating disorder or significant distress, which can have serious health implications. This behavior raises concerns about the adolescent's physical and mental well-being. The nurse should prioritize addressing potential eating disorders and body image issues in this situation. Choices A, B, and D, while important, do not pose an immediate risk to the adolescent's health or well-being compared to the potential consequences of disordered eating behavior.

2. UAP has lowered the head of the bed to change the linens for a client who is bedridden. Which observation...most immediate intervention by the nurse?

• A. A feeding is infusing at 40 mL/hr through an enteral feeding tube.
• B. The urine meter attached to the urinary drainage bag is completely full.
• C. There is a large dependent loop in the client's urinary drainage tubing.
• D. Purulent drainage is present around the insertion site of the feeding tube.

Correct answer: D

Rationale: The correct answer is D. Purulent drainage around the insertion site of the feeding tube indicates an infection, which requires immediate attention. This may be a sign of a serious complication that needs prompt nursing intervention to prevent further complications or deterioration in the client's condition. Choices A, B, and C do not indicate an immediate threat to the client's health. While option A highlights the infusion rate of the feeding, it does not pose an immediate risk compared to the presence of purulent drainage indicating infection.

3. Which nutritional assessment data should be collected to best reflect total muscle mass in an adolescent?

• A. Height in inches or centimeters.
• B. Weight in kilograms or pounds.
• C. Triceps skinfold thickness.
• D. Upper arm circumference.

Correct answer: D

Rationale: The correct answer is 'Upper arm circumference.' Upper arm circumference is a better indicator of total muscle mass in adolescents compared to height, weight, or triceps skinfold thickness. Triceps skinfold thickness primarily reflects subcutaneous fat, while weight and height are not specific to muscle mass. Upper arm circumference directly measures the muscle mass in the upper arm and can provide a more accurate assessment in this context. Therefore, choices A, B, and C are incorrect because they do not directly reflect total muscle mass in adolescents.

4. The healthcare provider is caring for a 17-month-old with acetaminophen poisoning. Which lab reports should the healthcare provider review first?

• A. Prothrombin time (PT) and partial thromboplastin time (PTT)
• B. Red blood cell and white blood cell counts
• C. Blood urea nitrogen and creatinine levels
• D. Liver enzymes (AST and ALT)

Correct answer: D

Rationale: In acetaminophen poisoning, liver damage is a significant concern due to the toxic effects of the drug on the liver. Liver enzymes such as AST (aspartate aminotransferase) and ALT (alanine aminotransferase) are essential markers to assess liver function and damage. Monitoring these enzymes early is crucial to detect hepatotoxicity and guide further management. Prothrombin time and partial thromboplastin time are coagulation studies and are not the priority in acetaminophen poisoning. Red and white blood cell counts are not specific to assess liver damage in this context. Blood urea nitrogen and creatinine levels are primarily used to evaluate kidney function, which is not the primary concern in acetaminophen poisoning.

5. A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take?

• A. Gently shake the container of medication prior to administration
• B. Transfer the medication to a medicine cup
• C. Place the client in a semi-Fowler’s position for medication administration
• D. Verify the dosage by measuring the liquid before administering it

Correct answer: A

Rationale: The correct action for the nurse to take is to gently shake the container of liquid medication before administration. Shaking the container ensures proper mixing of the medication, which is important to maintain uniformity of the dose. Transferring the medication to a medicine cup (choice B) may not be necessary for a small volume like 0.5 mL. Placing the client in a semi-Fowler's position (choice C) is not directly related to administering liquid medication orally. Verifying the dosage by measuring the liquid (choice D) is important but does not address the specific action needed to prepare the medication for administration.

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