Nursing Elites

1. How do you assess for dehydration in a pediatric patient?

• A. Check for dry mouth and decreased urine output
• B. Monitor skin turgor and capillary refill
• C. Assess for lethargy and irritability
• D. Monitor blood pressure and heart rate

Correct answer: A

Rationale: Correct! When assessing for dehydration in a pediatric patient, checking for dry mouth and decreased urine output are crucial indicators. Dry mouth indicates reduced fluid intake or dehydration, while decreased urine output suggests decreased renal perfusion secondary to dehydration. Skin turgor and capillary refill are more indicative of perfusion status rather than dehydration specifically. Lethargy and irritability can be present in dehydrated patients but are more general signs of illness. Monitoring blood pressure and heart rate are important in assessing dehydration severity but are not the initial signs used for assessment.

2. A client is being taught about prescribed asthma medications. Which of the following medications should the client use for treatment of an acute asthma attack?

• A. Beclomethasone
• B. Salmeterol
• C. Albuterol
• D. Montelukast

Correct answer: C

Rationale: Albuterol is the correct choice for treating acute asthma attacks because it is a short-acting bronchodilator that provides quick relief by relaxing the muscles in the airways. Beclomethasone (choice A) and Salmeterol (choice B) are long-acting medications used for controlling and preventing asthma symptoms but are not for immediate relief during an acute attack. Montelukast (choice D) is a leukotriene receptor antagonist used for asthma maintenance therapy and not for acute asthma attacks.

3. A healthcare professional is planning care for a client who has a prescription for mechanical restraints. Which of the following interventions should the healthcare professional include in the plan?

• A. Document the client's status every 60 minutes.
• B. Provide a staff member to stay with the client continuously.
• C. Measure vital signs every 4 hours.
• D. Obtain a prescription for the restraints every 8 hours.

Correct answer: B

Rationale: When a client has a prescription for mechanical restraints, it is essential to provide continuous monitoring for their safety and to observe any behavioral changes. Having a staff member stay with the client continuously allows for immediate intervention if needed. Documenting the client's status every 60 minutes (Choice A) may not provide real-time monitoring, which is crucial in this situation. While measuring vital signs every 4 hours (Choice C) is important, continuous observation takes precedence in this scenario. Obtaining a prescription for the restraints every 8 hours (Choice D) is not a necessary intervention once the initial prescription is in place.

4. A nurse at a long-term care facility is caring for a client who requires oral suctioning. Which of the following supplies should the nurse plan to use for this task?

• A. Yankauer catheter
• B. Bulb syringe
• C. Suction catheter
• D. Sterile gloves

Correct answer: A

Rationale: The correct answer is A: Yankauer catheter. The Yankauer catheter is specifically designed for oral suctioning, making it the most appropriate choice for this task. Choice B, the Bulb syringe, is typically used for suctioning small amounts of liquid from the nose or mouth. Choice C, the Suction catheter, is more commonly used for deep suctioning in the trachea or bronchi. Choice D, Sterile gloves, are necessary for infection control but are not the primary supply used for oral suctioning.

5. A nurse is implementing a plan of care for a client who is at risk for falls. Which of the following is an appropriate nursing action?

• A. Implement a regular toileting schedule
• B. Encourage the client to wear athletic socks when ambulating
• C. Place all four bed rails in the upright position
• D. Require a family member to remain at the bedside

Correct answer: A

Rationale: Implementing a regular toileting schedule is an appropriate nursing action for a client at risk for falls. This action can help prevent accidents related to rushing to the bathroom. Encouraging the client to wear athletic socks when ambulating (Choice B) is not safe as it can increase the risk of slipping and falling. Placing all four bed rails in the upright position (Choice C) can lead to entrapment or falls when the client tries to get out of bed. Requiring a family member to remain at the bedside (Choice D) may not always be feasible and does not directly address fall prevention strategies like the toileting schedule.

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