Nursing Elites

1. The mother of a child with acute laryngotracheobronchitis (LTB) asks why her child must be kept NPO. Which response would be the most correct?

• A. The epinephrine given causes nausea and vomiting.
• B. The child is being hydrated with IV fluids.
• C. The child is not hungry.
• D. The child's rapid respirations pose a risk for aspiration.

Correct answer: D

Rationale: The correct answer is D because rapid respirations predispose to aspiration in a child with acute laryngotracheobronchitis. Choice A is incorrect because epinephrine does not directly relate to the need for NPO status. Choice B is incorrect as hydration with IV fluids is not the primary reason for keeping the child NPO. Choice C is incorrect as the child being hungry is not the main concern when keeping a child NPO in this situation.

2. A client with a new colostomy is concerned about odor. What is the best advice the nurse can provide?

• A. Avoid high-fiber foods
• B. Use an odor-proof pouch
• C. Decrease fluid intake
• D. Increase dairy products in the diet

Correct answer: B

Rationale: The best advice the nurse can provide to a client concerned about odor from a new colostomy is to use an odor-proof pouch. This option helps control odors effectively by containing and masking any unpleasant smells. Avoiding high-fiber foods (Choice A) is not the best advice as fiber is essential for bowel health, and decreasing fluid intake (Choice C) can lead to dehydration and other complications. Increasing dairy products in the diet (Choice D) is not directly related to controlling odors from a colostomy.

3. A 2-year-old child with laryngotracheobronchitis (LTB) is fussy and restless in the oxygen tent. The oxygen level in the tent is 25%, and blood gases are normal. What would be the correct action by the nurse?

• A. Restrain the child in the tent and notify the health care provider.
• B. Increase the oxygen concentration in the tent.
• C. Take the child out of the tent and into the playroom.
• D. Ask the mother for help in comforting the child.

Correct answer: B

Rationale: The child with LTB should be placed in the mist tent with 30% oxygen. Restlessness is caused by poor oxygenation. The child should not be taken out of the oxygenated tent. While the mother could be asked to help comfort the child, and the health care provider may be notified, the priority is to set the oxygen at the correct level.

4. During a paracentesis, two liters of fluid are removed from the abdomen of a client with ascites. A drainage bag is placed, and 50 ml of straw-colored fluid drains within the first hour. What action should the nurse implement?

• A. Palpate for abdominal distention
• B. Send fluid to the lab for analysis
• C. Continue to monitor the fluid output
• D. Clamp the drainage tube for 5 minutes

Correct answer: C

Rationale: Continuing to monitor the fluid output is the appropriate action in this situation. Monitoring the fluid output helps the nurse assess the client's ongoing response to the procedure and detect any sudden changes, such as increased or decreased drainage rate, which could indicate complications. Palpating for abdominal distention, sending fluid to the lab for analysis, or clamping the drainage tube are not necessary actions at this point, as the priority is to monitor the client's condition post-procedure.

5. A client with partial-thickness burns to the lower extremities is scheduled for whirlpool therapy to debride the burned area. Which intervention should the nurse implement before transporting the client to the physical therapy department?

• A. Apply a sterile dressing to the wound.
• B. Administer an analgesic.
• C. Encourage the client to drink fluids.
• D. Ensure the client's nutritional needs are met.

Correct answer: B

Rationale: Administering an analgesic before whirlpool therapy is the priority intervention in this scenario. Whirlpool therapy for debridement can be painful for the client with partial-thickness burns. Administering an analgesic before the procedure helps manage pain during the debridement process, ensuring the client's comfort. Applying a sterile dressing (Choice A) may be necessary after the whirlpool therapy but is not the immediate pre-transport intervention. Encouraging the client to drink fluids (Choice C) and ensuring nutritional needs are met (Choice D) are important aspects of care but are not specifically related to preparing the client for whirlpool therapy.

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