Nursing Elites

1. The patient taking spironolactone (Aldactone) makes a statement indicating effective teaching. Which statement shows understanding of the teaching?

• A. I will use salt substitutes to lower my sodium intake
• B. I will increase my intake of foods that are high in potassium
• C. I will call my doctor if I begin having menstrual irregularities
• D. I will take this medication at bedtime each evening

Correct answer: C

Rationale: The correct answer is C because spironolactone is a potassium-sparing diuretic that can cause endocrine effects like menstrual irregularities. Therefore, the patient recognizing the need to report such changes indicates effective teaching. Choices A and B are incorrect as salt substitutes and high-potassium foods should be avoided with spironolactone. Choice D is also incorrect because diuretics, including spironolactone, are ideally taken in the morning to prevent disturbances in sleep due to nocturia.

2. When teaching a school-age child and the parent how to administer insulin, which of the following instructions should the nurse include?

• A. Store the insulin in the refrigerator after each use.
• B. Rotate injection sites each time you give the injection.
• C. You should give the insulin at room temperature.
• D. Administer the insulin within 30 minutes of each meal.

Correct answer: C

Rationale: It is essential to give insulin at room temperature to prevent discomfort during administration. Cold insulin can cause stinging and pain, which can be avoided by allowing the insulin to reach room temperature before administration. Storing insulin in the refrigerator is correct for long-term storage, but it should be brought to room temperature before use. Rotating injection sites is important to prevent lipohypertrophy, a condition characterized by fatty lumps that can develop if injections are consistently given in the same area. Administering insulin within 30 minutes of a meal is generally recommended to match the insulin peak action with the peak glucose levels after eating, but giving insulin at room temperature is more crucial to ensure comfort and proper absorption.

3. A nurse is caring for a child who has a new diagnosis of osteomyelitis. Which of the following actions should the nurse take?

• A. Administer aspirin for pain.
• B. Apply ice to the affected area.
• C. Monitor the child�s weight daily.
• D. Limit the child's activity.

Correct answer: C

Rationale: The nurse should monitor the child�s weight daily to assess the effectiveness of treatment for osteomyelitis and detect potential complications.

4. A 6-year-old child with daytime enuresis complains of dysuria and urgency. What does the nurse recognize these signs and symptoms indicate?

• A. Urinary tract infection
• B. Nephrotic syndrome
• C. Acute glomerulonephritis
• D. Vesicoureteral reflux

Correct answer: A

Rationale: The signs and symptoms of dysuria and urgency in a child with daytime enuresis typically indicate a urinary tract infection (UTI). These symptoms, along with urinary frequency and pain during urination, are common manifestations of a UTI in children. Nephrotic syndrome is characterized by edema, proteinuria, hypoalbuminemia, and hyperlipidemia, rather than dysuria and urgency. Acute glomerulonephritis presents with hematuria, proteinuria, hypertension, and oliguria, not dysuria and urgency. Vesicoureteral reflux can lead to recurrent UTIs but does not directly cause dysuria and urgency.

5. When planning care for a newborn with esophageal atresia and tracheoesophageal fistula, which is the priority nursing diagnosis?

• A. Ineffective Tissue Perfusion
• B. Ineffective Infant Feeding Pattern
• C. Acute Pain
• D. Risk for Aspiration

Correct answer: D

Rationale: The priority nursing diagnosis for a newborn with esophageal atresia and tracheoesophageal fistula is 'Risk for Aspiration' because of the potential respiratory complications associated with these conditions. The newborn is at a higher risk of aspirating oral or gastric contents due to the abnormal connections between the esophagus and trachea, posing a serious threat to the airway and lungs. Addressing this risk is crucial to prevent respiratory distress and maintain the airway's patency, making it the priority nursing diagnosis in this scenario. 'Ineffective Tissue Perfusion' is not the priority as respiratory compromise takes precedence over perfusion concerns. 'Ineffective Infant Feeding Pattern' may be relevant but addressing the risk of aspiration is more critical. 'Acute Pain' is not the priority compared to the life-threatening risk of aspiration.

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