Nursing Elites

1. The patient is receiving a heparin infusion for the treatment of pulmonary embolism. Which assessment finding is most likely related to an adverse effect of heparin?

• A. HR of 60 bpm
• B. BP of 160/88
• C. Discolored urine
• D. Inspiratory wheezing

Correct answer: C

Rationale: The primary and most serious adverse effect of heparin is bleeding. However, discolored urine can indicate bleeding into the urinary tract, which is a potential adverse effect of heparin therapy. While changes in heart rate (HR) and blood pressure (BP) can occur due to various reasons, discolored urine specifically points towards a potential adverse effect related to heparin therapy.

2. When receiving change-of-shift report for children, which child should the nurse assess first?

• A. A toddler who has a concussion and an episode of forceful vomiting
• B. An adolescent with infective endocarditis who reports having a headache
• C. An adolescent who was placed into Halo traction 1 hour ago and rates his pain at a 6 on a 0-10 scale
• D. A school-age child with acute glomerulonephritis and brown-colored urine

Correct answer: A

Rationale: The nurse should assess the toddler with a concussion and an episode of forceful vomiting first when receiving change-of-shift report for children. Forceful vomiting in a toddler with a concussion indicates increased intracranial pressure, requiring immediate assessment and intervention to prevent further complications.

3. During a developmental screening, a 4-year-old child is asked to perform a task. Which of the following tasks should the nurse expect the child to perform?

• A. Draw a stick figure with seven body parts
• B. Draw a circle
• C. Identify right from left hand
• D. Tie their shoelaces

Correct answer: B

Rationale: At 4 years old, children are typically able to draw a circle, which is a developmental milestone for their age. Drawing a stick figure with specific body parts might be beyond their developmental level, identifying right from left hand can be challenging, and tying shoelaces requires more advanced motor skills.

4. What is the next food texture after 'soft and bite-sized pieces of meltable and soft-solid foods'?

• A. Regular
• B. Liquidized
• C.
• D. Minced and Moist

Correct answer: A

Rationale: After mastering soft and bite-sized pieces, children typically progress to regular table foods.

5. A child is being assessed for acute poststreptococcal glomerulonephritis (APSGN). Which of the following findings should the nurse expect?

• A. Hematuria
• B. Polyuria
• C. Hypertension
• D. Diarrhea

Correct answer: C

Rationale: In acute poststreptococcal glomerulonephritis (APSGN), hypertension is a common finding due to fluid retention and decreased kidney function. This condition often presents with hypertension as a result of sodium and water retention, as well as reduced glomerular filtration rate. Hematuria, not diarrhea, is also a common symptom of APSGN due to inflammation and damage to the glomeruli. Polyuria, an increase in urine output, is not a typical finding in APSGN unless severe kidney damage leads to decreased urine concentrating ability.

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