Nursing Elites

1. The nurse is discussing with a group of students the disease Kawasaki. What statement made by a student about Kawasaki disease is incorrect?

• A. It is also called mucocutaneous lymph node syndrome because it affects the mucous membranes (inside the mouth, throat, and nose), skin, and lymph nodes.
• B. In the second phase of the disease, findings include peeling of the skin on the hands and feet with joint and abdominal pain.
• C. Kawasaki disease occurs most often in boys, children younger than age 5, and children of Hispanic descent.
• D. Initially findings are a sudden high fever, usually above 104 degrees Fahrenheit, which lasts 1 to 2 weeks.

Correct answer: C

Rationale: The correct answer is C. Kawasaki disease occurs most often in boys and children younger than age 5, but there is no specific predisposition to children of Hispanic descent. Choice A is accurate, as Kawasaki disease does affect mucous membranes, skin, and lymph nodes. Choice B is correct, as peeling of the skin on the hands and feet with joint and abdominal pain are findings in the second phase of the disease. Choice D is accurate since initially, there is a sudden high fever that lasts 1 to 2 weeks.

2. Although non-steroidal anti-inflammatory drugs such as ibuprofen (Motrin) are beneficial in managing arthritis pain, the nurse should caution clients about which of the following common side effects?

• A. Urinary incontinence
• B. Constipation
• C. Nystagmus
• D. Occult bleeding

Correct answer: D

Rationale: The correct answer is D: Occult bleeding. Non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen are known to cause gastrointestinal side effects, including occult bleeding. Occult bleeding refers to bleeding in the gastrointestinal tract that may not be visible in the stool, leading to potential complications like anemia. Urinary incontinence (choice A) is not a common side effect of NSAIDs. Constipation (choice B) is also not a typical side effect associated with NSAIDs. Nystagmus (choice C) is an involuntary eye movement and is not a common side effect of NSAIDs. Therefore, the nurse should caution clients about the risk of occult bleeding when using NSAIDs for arthritis pain management.

3. A client who is 2 days postoperative following abdominal surgery is transitioning from a clear liquid diet to a full liquid diet. The nurse should remind the client that which of the following items is included in a full liquid diet?

• A. Creamed peas
• B. Cottage cheese
• C. Chocolate pudding
• D. Applesauce

Correct answer: C

Rationale: The correct answer is C, chocolate pudding. A full liquid diet consists of smooth, creamy foods like pudding. Creamed peas (choice A) are not typically allowed on a full liquid diet as they may contain solid pieces. Cottage cheese (choice B) and applesauce (choice D) are also not part of a full liquid diet as they are not in liquid form.

4. A nurse is reinforcing teaching with the parent of a toddler about appropriate snacks. Which of the following foods should the nurse include in the teaching?

• A. Sliced bananas
• B. Raw celery
• C. Peanut butter
• D. Marshmallows

Correct answer: A

Rationale: The correct answer is A: Sliced bananas. Sliced bananas are a healthy and safe snack option for toddlers as they provide essential nutrients and are easy to chew. Bananas are a good source of potassium and fiber. Choice B, raw celery, may pose a choking hazard for toddlers due to its stringy texture. Choice C, peanut butter, can also be a choking hazard and may not be suitable for all toddlers due to potential allergies. Choice D, marshmallows, are high in sugar and low in nutrients, making them an unhealthy choice for toddler snacks.

5. An antibiotic IM injection for a 2-year-old child is ordered. The total volume of the injection equals 2.0 ml. The correct action is to

• A. administer the medication in 2 separate injections
• B. give the medication in the ventrogluteal site
• C. call to get a smaller volume ordered
• D. check with the pharmacy for a liquid form of the medication

Correct answer: A

Rationale: Administering the medication in 2 separate injections is the correct action. When the total volume of an injection is relatively large for a specific site, dividing it into smaller volumes and administering them separately is a safer practice to prevent discomfort, tissue damage, or absorption issues. Giving the medication in the ventrogluteal site can be appropriate for IM injections but does not address the issue of the total volume being too high for a single injection. Calling to get a smaller volume ordered may delay treatment and is not necessary when a safe administration method is available. Checking with the pharmacy for a liquid form of the medication does not directly address the issue of the total volume being too high for a single injection, and changing the formulation may not be necessary if the correct administration technique can be applied.

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