Nursing Elites

1. In a hospitalized child receiving IV fluids for dehydration, what is the best indicator that the child’s dehydration is improving?

• A. The child’s urine output increases
• B. The child’s skin turgor is normal
• C. The child’s weight increases
• D. The child’s vital signs are stable

Correct answer: A

Rationale: An increase in urine output is a reliable indicator of improving dehydration in a child. It signifies that the kidneys are functioning better, helping to restore fluid balance in the body. Monitoring urine output is crucial in assessing hydration status and response to treatment. Choices B, C, and D are not the best indicators of improving dehydration. Normal skin turgor is helpful but may not change immediately with improving hydration. Weight increase may reflect retained fluids rather than improved hydration status. Stable vital signs are important but may not always indicate improving dehydration.

2. While assessing the vital signs of a 10-year-old who underwent a tonsillectomy this morning, the nurse observes the child swallowing every 2-3 minutes. Which assessment should the nurse implement?

• A. Inspect the posterior oropharynx
• B. Assess for teeth clenching or grinding
• C. Touch the tonsillar pillars to stimulate the gag reflex
• D. Ask the child to speak to evaluate a change in voice tone

Correct answer: A

Rationale: Frequent swallowing post-tonsillectomy may indicate bleeding. Inspecting the posterior oropharynx is essential to assess for any signs of bleeding, such as fresh blood or clots, which may necessitate immediate intervention. Option B is incorrect as teeth clenching or grinding is not directly related to the observation of frequent swallowing in this scenario. Option C is incorrect because stimulating the gag reflex is not necessary at this point and may be uncomfortable for the child. Option D is incorrect as evaluating a change in voice tone is not relevant to the situation of observing frequent swallowing.

3. A 2-year-old child with respiratory syncytial virus (RSV) is being treated in the hospital. What should the healthcare provider monitor for in this child?

• A. Increased urine output.
• B. Decreased respiratory rate.
• C. Labored breathing.
• D. Improved appetite.

Correct answer: C

Rationale: Labored breathing is a critical sign of worsening respiratory distress in children with RSV. It indicates that the child's condition may be deteriorating, requiring prompt intervention to ensure adequate oxygenation and prevent respiratory failure. Monitoring for labored breathing allows healthcare providers to promptly assess and manage the child's respiratory status, potentially preventing further complications associated with RSV infection.

4. What is the priority intervention for a 16-year-old client with a history of depression who is brought to the emergency department after taking an overdose of acetaminophen?

• A. Administer activated charcoal
• B. Place the client on continuous cardiac monitoring
• C. Prepare for gastric lavage
• D. Administer N-acetylcysteine as prescribed

Correct answer: D

Rationale: The priority intervention for a client who has taken an acetaminophen overdose is to administer N-acetylcysteine promptly. N-acetylcysteine is the antidote for acetaminophen overdose and helps prevent liver damage. Activated charcoal may be used in certain cases, but N-acetylcysteine takes precedence as it directly counteracts the toxic effects of acetaminophen. Continuous cardiac monitoring and gastric lavage are not the priority interventions for acetaminophen overdose. Administering N-acetylcysteine is crucial to prevent liver damage and address the overdose, making it the most urgent action in this scenario.

5. What instructions should the nurse provide to the parents about the treatment of head lice in a 3-year-old boy who has been confirmed to have head lice?

• A. Wash the child's bed linens and clothing in hot soapy water.
• B. Dispose of the child's brushes, combs, and other hair accessories.
• C. Rewash the child's hair following a 24-hour isolation period.
• D. Take the child to a hair salon for a shampoo and shorter haircut.

Correct answer: A

Rationale: The correct instruction for the nurse to provide to the parents is to wash the child's bed linens and clothing in hot soapy water. This is essential to eliminate head lice as they can survive on bedding and clothing. It is also important to wash any other items that the child may have used or come into contact with, such as brushes and combs, to prevent reinfestation. Rewashing the child's hair following an isolation period is not necessary, and taking the child to a hair salon for a shampoo and shorter haircut is not a recommended treatment for head lice.

Similar Questions