Nursing Elites

1. The nurse is providing care to a child with a long-leg hip spica cast. What is the priority nursing diagnosis?

• A. Risk for impaired skin integrity due to the cast and its location.
• B. Deficient knowledge related to cast care.
• C. Risk for delayed development related to immobility.
• D. Self-care deficit related to immobility.

Correct answer: A

Rationale: The correct answer is A: Risk for impaired skin integrity due to the cast and its location. When a child has a long-leg hip spica cast, the priority nursing diagnosis is to prevent impaired skin integrity. This is because the child's mobility is restricted, and pressure from the cast can lead to skin breakdown. Option B is incorrect as while education is essential, it is not the priority when skin integrity is at risk. Option C is incorrect because while immobility can impact development, immediate skin integrity concerns take precedence. Option D is incorrect as self-care deficit, while important, is secondary to preventing skin breakdown in this scenario.

2. A nurse is caring for an infant with a tentative diagnosis of hypertrophic pyloric stenosis (HPS). What is most important for the nurse to assess?

• A. Quality of the cry
• B. Signs of dehydration
• C. Coughing up feedings
• D. Characteristics of the stool

Correct answer: B

Rationale: The correct answer is B: Signs of dehydration. Infants with hypertrophic pyloric stenosis (HPS) are at high risk of dehydration due to frequent vomiting. Assessing for signs of dehydration, such as decreased urine output, dry mucous membranes, and sunken fontanelles, is crucial for early intervention and management. Choices A, C, and D are not the most critical assessments for HPS. The quality of the cry (choice A) may not provide as much relevant information in this case. Coughing up of feedings (choice C) may be a symptom but is not as crucial as assessing for dehydration. Characteristics of the stool (choice D) are important but assessing for signs of dehydration takes precedence due to the immediate risk it poses to the infant's health.

3. At 7 AM, a healthcare professional receives the information that an adolescent with diabetes has a 6:30 AM fasting blood glucose level of 180 mg/dL. What is the priority nursing action at this time?

• A. Encourage the adolescent to start exercising.
• B. Ask the adolescent to obtain an immediate glucometer reading.
• C. Inform the adolescent that a complex carbohydrate such as cheese should be eaten.
• D. Tell the adolescent that the prescribed dose of rapid-acting insulin should be administered.

Correct answer: D

Rationale: The correct priority nursing action in this situation is to administer the prescribed dose of rapid-acting insulin. Rapid-acting insulin is necessary to help lower the elevated blood glucose level quickly, thereby preventing potential complications of hyperglycemia. Encouraging exercise, obtaining a glucometer reading, or suggesting consumption of complex carbohydrates like cheese may not address the immediate need to bring down the high blood glucose level effectively. Exercise could potentially raise blood glucose levels, obtaining a glucometer reading may delay necessary treatment, and consuming complex carbohydrates can further elevate blood glucose levels in this scenario.

4. The nurse is caring for a 10-year-old with Duchenne muscular dystrophy. As part of the plan of care, the nurse focuses on maintaining his cardiopulmonary function. Which intervention would the nurse implement to best promote maximum chest expansion?

• A. Deep-breathing exercises
• B. Upright positioning
• C. Coughing
• D. Chest percussion

Correct answer: B

Rationale: Upright positioning is the optimal intervention to promote maximum chest expansion in a child with Duchenne muscular dystrophy. By placing the child in an upright position, gravity can assist in expanding the chest cavity, facilitating better lung expansion and improving breathing efficiency. Deep-breathing exercises may be beneficial but are not as effective in maximizing chest expansion as upright positioning. Coughing and chest percussion focus more on airway clearance and are not directly aimed at promoting chest expansion.

5. A nurse is caring for a child with a diagnosis of acute lymphoblastic leukemia (ALL). What is the priority nursing intervention?

• A. Administering chemotherapy
• B. Preventing infection
• C. Monitoring for signs of bleeding
• D. Providing nutritional support

Correct answer: B

Rationale: The correct answer is preventing infection. In caring for a child with acute lymphoblastic leukemia (ALL), preventing infection is the priority nursing intervention. Children with ALL are immunocompromised due to the disease and its treatment, making them more susceptible to infections. Administering chemotherapy, while important, is not the priority as preventing infection takes precedence to avoid complications. Monitoring for signs of bleeding and providing nutritional support are also essential components of care for a child with ALL, but preventing infection is the priority to ensure the child's safety and well-being.

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