Nursing Elites

1. When admitting a 5-month-old who has vomited 9 times in the past 6 hours, what should the healthcare provider observe for signs of which overall imbalance?

• A. Metabolic acidosis
• B. Metabolic alkalosis
• C. Increased serum hemoglobin levels
• D. Decreased serum potassium levels

Correct answer: B

Rationale: When a 5-month-old infant vomits multiple times, there is a risk of developing metabolic alkalosis due to the loss of stomach acid. Metabolic alkalosis is characterized by elevated pH and bicarbonate levels. It is caused by the loss of hydrogen ions from the body, often through vomiting. Metabolic acidosis (choice A) is unlikely in this scenario because it is more commonly associated with conditions like renal failure or diabetic ketoacidosis. Choice C, increased serum hemoglobin levels, is not typically a direct consequence of vomiting. Choice D, decreased serum potassium levels, may occur with vomiting but is not the primary concern when a patient is vomiting excessively.

2. The nurse is caring for a 17-month-old child with acetaminophen poisoning. Which laboratory reports should the nurse 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 drug's metabolism in the liver. Monitoring liver enzymes such as AST and ALT is crucial as they indicate liver function and damage. Prothrombin time (PT) and partial thromboplastin time (PTT) (Choice A) are coagulation studies and are not the priority in acetaminophen poisoning. Red blood cell and white blood cell counts (Choice B) are not directly related to acetaminophen poisoning. Blood urea nitrogen and creatinine levels (Choice C) assess kidney function, but liver enzymes are more specific for evaluating liver damage in acetaminophen poisoning.

3. A patient is placed in the Sims' position. Which areas will the nurse observe for pressure points?

• A. Chin, elbow, hips
• B. Ileum, clavicle, humerus
• C. Shoulder, anterior iliac spine, ankles
• D. Occipital region of the head, coccyx, heels

Correct answer: B

Rationale: When a patient is placed in the Sims' position, the nurse should observe pressure points on the ileum, clavicle, humerus, knees, and ankles. Choice A is incorrect as the chin and hips are not typically pressure points in the Sims' position. Choice C is incorrect as the shoulder and anterior iliac spine are not commonly observed pressure points in this position. Choice D is also incorrect as the occipital region of the head, coccyx, and heels are not pressure points commonly associated with the Sims' position.

4. What is the first step a healthcare professional should take when preparing to provide tracheostomy care?

• A. Perform hand hygiene
• B. Gather equipment
• C. Explain the procedure
• D. Assess the client

Correct answer: A

Rationale: Performing hand hygiene is the initial step a healthcare professional should take when preparing to provide tracheostomy care. This step is crucial to prevent the transmission of pathogens and reduce the risk of infection to the client. By cleansing the hands, the healthcare professional ensures patient safety. While gathering equipment, explaining the procedure, and assessing the client are essential components of tracheostomy care, they should occur after performing hand hygiene to maintain aseptic technique and minimize the risk of introducing harmful microorganisms to the client.

5. A client has acute renal failure. Which of the following assessments provides the most accurate measure of the client's fluid status?

• A. Daily weight
• B. Intake and output
• C. Urine specific gravity
• D. Peripheral edema

Correct answer: A

Rationale: Daily weight is the most accurate measure of fluid status in a client with acute renal failure. Fluctuations in weight reflect changes in body fluid volume, including both fluid retention or loss. Intake and output, while important, may not always accurately reflect overall fluid status as it does not account for insensible losses. Urine specific gravity can provide information on urine concentration but does not offer a comprehensive assessment of overall fluid status. Peripheral edema, although a sign of fluid retention, is a more subjective assessment and may not always accurately reflect the client's fluid status like daily weight monitoring does.

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