Nursing Elites

1. An infant with congestive heart failure is receiving diuretic therapy. A nurse is closely monitoring the intake and output. The nurse uses which most appropriate method to assess the urine output?

• A. Weighing the diapers
• B. Inserting a Foley catheter
• C. Comparing intake with output
• D. Measuring the amount of water added to formula

Correct answer: A

Rationale: Weighing the diapers is the most appropriate method to assess urine output in infants. Diapers will absorb and retain urine, providing a measurable indicator of urine output without invasive procedures. This method is non-invasive, simple, and convenient for monitoring urine output, especially in infants who may not be able to use other urine output measurement techniques. Inserting a Foley catheter is invasive and not indicated for routine urine output monitoring in infants. Comparing intake with output does not directly measure urine output. Measuring the amount of water added to formula does not provide an accurate assessment of urine output.

2. Which type of diabetes mellitus (DM) is most likely the result of heterogeneous risk factors, making it preventable?

• A. Type 1
• B. Type 2
• C. Type 1 and 2
• D. Gestational diabetes

Correct answer: B

Rationale: Type 2 diabetes mellitus is most likely the result of heterogeneous risk factors, such as lifestyle choices and genetics, making it preventable. Type 1 diabetes, on the other hand, is an autoimmune condition that is not preventable. Gestational diabetes occurs during pregnancy and is not entirely preventable. Type 1 and 2 diabetes are distinct conditions, with Type 2 being the type associated with preventable risk factors.

3. A 2-year-old client is admitted for an acute asthma episode. The hospital provides family-centered care. In explaining the program to the parents, the nurse would explain that the parents are:

• A. Required to implement all personal hygiene care for their child.
• B. Encouraged to be as involved with the child's care as they are comfortable being.
• C. Requested to administer all oral medications.
• D. Expected to be present at the child's bedside.

Correct answer: B

Rationale: Family-centered care involves encouraging parents to actively participate in their child's care based on their comfort level. This approach promotes collaboration between healthcare providers and families, enhancing the quality of care and ensuring the family's involvement in decision-making. Choice A is incorrect because parents are encouraged to participate, not required to implement all personal hygiene care. Choice C is incorrect as it implies a specific action rather than the broader concept of involvement. Choice D is incorrect as it focuses solely on physical presence rather than active participation in care.

4. A 3-year-old child has been admitted to your pediatric ward. The doctor gave a provisional diagnosis of respiratory tract infection. After careful assessment and history, a final diagnosis of lower respiratory infection was made. Which of the following signs will confirm the diagnosis?

• A. Cough
• B. Fever
• C. Inability to lie supine
• D. Inability to eat

Correct answer: C

Rationale: Inability to lie supine is a characteristic sign of lower respiratory infection. This positioning preference is often seen in patients with lower respiratory infections due to discomfort or difficulty breathing when lying flat on their back. While cough and fever are common symptoms associated with respiratory infections, they are not specific to lower respiratory infections. Inability to eat may indicate general illness or discomfort but is not a specific indicator of lower respiratory infection.

5. How can a new mother tell if her baby is getting enough breast milk?

• A. If your baby sleeps through the night, they are getting enough milk.
• B. If your baby has six to eight wet diapers a day, they are getting enough milk.
• C. If your baby cries frequently, they are getting enough milk.
• D. If your baby is awake and alert, they are getting enough milk.

Correct answer: B

Rationale: The correct answer is B. If a new mother observes that her baby has six to eight wet diapers a day, it indicates that the baby is getting enough breast milk. This is a crucial indicator of adequate milk intake and hydration in infants. Conversely, choices A, C, and D are incorrect. A baby sleeping through the night, crying frequently, or being awake and alert are not reliable indicators of sufficient breast milk intake. It is essential for new mothers to track their baby's diaper output to ensure they are receiving the necessary nutrition.

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