Nursing Elites

1. The healthcare provider is assessing an infant brought to the clinic due to diarrhea. The infant is alert but has dry mucous membranes. Which additional assessment data indicates to the healthcare provider that the infant is experiencing an early to moderate stage of dehydration?

• A. Bradycardia
• B. Tachycardia
• C. Increased blood pressure
• D. Normal fontanels

Correct answer: B

Rationale: Tachycardia is a common early sign of dehydration in infants, especially when presenting with dry mucous membranes and diarrhea. The increased heart rate is the body's compensatory mechanism to maintain cardiac output in response to dehydration. Bradycardia, increased blood pressure, and normal fontanels are not typically associated with early to moderate dehydration in infants.

2. What is the priority nursing intervention when caring for a neonate born with bladder exstrophy?

• A. Measuring intake and output
• B. Inserting a Foley catheter
• C. Covering the defect with sterile plastic wrap
• D. Palpating the bladder mass to ensure urine is expelled

Correct answer: C

Rationale: The priority nursing intervention when caring for a neonate born with bladder exstrophy is to cover the defect with sterile plastic wrap. This intervention helps prevent infection and maintains a moist environment, promoting optimal healing and reducing the risk of complications.

3. When educating a parent of an infant with a new prescription for digoxin, which instruction should the nurse provide?

• A. Repeat the dose if the infant vomits.
• B. Mix the medication with food.
• C. Give the medication with meals.
• D. Monitor the infant's heart rate prior to administering the medication.

Correct answer: D

Rationale: The correct answer is D: 'Monitor the infant's heart rate prior to administering the medication.' It is crucial for the nurse to monitor the infant's heart rate before giving digoxin to identify any signs of digoxin toxicity early. Heart rate assessment helps in detecting and preventing potential complications associated with digoxin use. Choices A, B, and C are incorrect. Repeating the dose if the infant vomits can lead to overdose, mixing the medication with food may alter its absorption, and giving the medication with meals can affect its effectiveness. Therefore, the priority is to monitor the infant's heart rate to ensure safe administration of digoxin.

4. Which is the appropriate intervention when providing care to a child diagnosed with nephrotic syndrome, who is edematous and on bed rest?

• A. Monitor blood pressure every 30 minutes.
• B. Reposition every 2 hours.
• C. Limit visitors.
• D. Encourage fluids.

Correct answer: B

Rationale: Repositioning every 2 hours is crucial in preventing skin breakdown in an edematous child on bed rest. This intervention helps redistribute pressure and maintain skin integrity, reducing the risk of pressure ulcers. It is an essential part of care for patients with limited mobility to ensure their comfort and prevent complications related to immobility.

5. A caregiver is learning about administering digoxin to a toddler. Which statement by the caregiver indicates an understanding of the teaching?

• A. I will mix the medication with a small amount of juice.
• B. I will give the medication with meals.
• C. I will give a second dose if my child vomits.
• D. I will give my child water after giving the medication.

Correct answer: D

Rationale: The correct statement is D because giving the child water after administering digoxin helps ensure the medication is swallowed properly. Mixing the medication with juice (choice A) may affect its absorption. Giving the medication with meals (choice B) may interfere with its effectiveness. Administering a second dose if the child vomits (choice C) is not recommended as it may lead to an overdose.

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