Nursing Elites

1. Following a bout of diarrhea, which foods should be offered to the school-age child?

• A. Apricots and peaches
• B. Chocolate milk
• C. Applesauce and milk
• D. Bananas and rice

Correct answer: D

Rationale: After rehydration, it is important to offer foods that are nonirritating to the bowel to the child. Bananas and rice are considered the best options as they are least likely to irritate the gastrointestinal tract. Apricots, peaches, and applesauce are fruits that may cause GI irritation, while milk, including chocolate milk, can also be irritating to the bowel. Therefore, the optimal choice for a child recovering from diarrhea would be bananas and rice.

2. The healthcare provider writes several prescriptions for a client diagnosed with hospital-acquired pneumonia (HAP) that include a combination of broad-spectrum antibiotics. Which intervention should the nurse implement first?

• A. Administer the first dose of antibiotics.
• B. Obtain a chest X-ray.
• C. Administer oxygen therapy.
• D. Collect blood specimens for culture prior to starting antibiotic therapy.

Correct answer: D

Rationale: Collecting blood specimens for culture prior to starting antibiotic therapy is the priority intervention in a client diagnosed with hospital-acquired pneumonia. This step is crucial to identify the causative organism responsible for the infection and ensure that the antibiotics prescribed are appropriate for effective treatment. Administering antibiotics before collecting cultures may interfere with the accuracy of culture results, potentially leading to inappropriate treatment. While administering the first dose of antibiotics is important, obtaining a chest X-ray and administering oxygen therapy are secondary interventions compared to identifying the causative organism through blood cultures.

3. What is the priority patient problem for the parents of a newborn born with cleft lip and palate?

• A. Parental role conflict
• B. Risk for delayed growth and development
• C. Risk for impaired attachment
• D. Anticipatory grieving

Correct answer: C

Rationale: The correct answer is C: Risk for impaired attachment. Parents of a newborn with cleft lip and palate may face challenges in bonding with their child due to the physical appearance, impacting attachment. Promoting bonding between parents and the infant is crucial in this situation. Choice A (Parental role conflict) is incorrect as it focuses on conflicting roles rather than the attachment issue. Choice B (Risk for delayed growth and development) is not the priority issue in this scenario as the immediate concern is establishing a healthy attachment. Choice D (Anticipatory grieving) is not the priority patient problem as it pertains more to the emotional response to an anticipated loss, which is not the primary concern at this stage.

4. The nurse caring for a hospitalized older client with a left hip fracture as a result of a fall at home notices different assessment findings. Which assessment finding warrants immediate intervention by the nurse?

• A. Pain rated 7/10 on the pain scale.
• B. Mild swelling at the fracture site.
• C. Small amount of bleeding from the surgical site.
• D. Left extremity capillary refill greater than 5 seconds.

Correct answer: D

Rationale: The correct answer is D. A left extremity capillary refill greater than 5 seconds indicates poor blood flow to the extremity, which is a sign of compromised circulation. This finding requires immediate intervention by the nurse to prevent complications such as tissue damage or necrosis. Choices A, B, and C are important assessments but do not indicate an immediate need for intervention like the delayed capillary refill in choice D.

5. An adult client who received partial-thickness and full-thickness burns over 40% of the body in a house fire is admitted to the inpatient burn unit.

• A. Normal Saline
• B. Lactated Ringer’s
• C. 5% Dextrose in water
• D. 0.45% Sodium Chloride

Correct answer: B

Rationale: In burn patients, Lactated Ringer's solution is preferred over other options as it helps in restoring fluid and electrolyte balance effectively. Lactated Ringer's contains electrolytes (sodium, potassium, calcium) that closely mimic the body's natural composition, making it a suitable choice for fluid resuscitation in burn injuries. Normal Saline (Choice A) lacks electrolytes like potassium and calcium, which are essential in burn management. 5% Dextrose in water (Choice C) is a hypotonic solution and is not the ideal choice for fluid resuscitation in burn patients. 0.45% Sodium Chloride (Choice D) is a hypotonic solution mainly used for conditions requiring free water replacement rather than volume expansion needed in burn injuries.

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