Nursing Elites

1. The nurse notes that a child has lost 3.6 kg (8 lb) after 4 days of hospitalization for acute glomerulonephritis. What is the most likely cause of this weight loss?

• A. Poor appetite
• B. Reduction of edema
• C. Restriction to bed rest
• D. Increased potassium intake

Correct answer: B

Rationale: The weight loss is most likely due to the reduction of edema, as glomerulonephritis often causes fluid retention that resolves with treatment, leading to significant weight loss.

2. Which clinical manifestations should the nurse anticipate when assessing a child for hypoglycemia?

• A. Lethargy
• B. Thirst
• C. Nausea and vomiting
• D. Shaky feeling and dizziness

Correct answer: D

Rationale: The correct answer is D: 'Shaky feeling and dizziness.' Hypoglycemia in children often presents with symptoms like shakiness, dizziness, sweating, hunger, and irritability. These symptoms occur because the brain and body are deprived of the glucose they need to function properly. Choices A, B, and C are incorrect because lethargy, thirst, nausea, and vomiting are not typically primary manifestations of hypoglycemia in children.

3. A parent brings their 2-year-old son in for a well visit. The nurse assesses his growth since the last appointment. Which finding should concern the nurse?

• A. Prominent abdomen
• B. Forward curve of the spine in the sacral area
• C. Increase in height of 5 inches in the past year
• D. Total weight gain of 15 lb in the past year

Correct answer: D

Rationale: The correct answer is D. A total weight gain of 15 lb in one year for a 2-year-old is excessive and may indicate an underlying issue such as a metabolic disorder or overfeeding. This rapid weight gain can put the child at risk for health problems. Choices A, B, and C are not typically concerning findings in a 2-year-old. A prominent abdomen can be normal at this age due to a toddler's slightly protruding belly, a forward curve of the spine at the sacral area is a typical finding in young children, and an increase in height of 5 inches in a year is within the expected range of growth for a 2-year-old.

4. After surgery yesterday for gastroesophageal reflux, the nurse finds that the infant has somehow removed the nasogastric (NG) tube. What nursing action is most appropriate to perform at this time?

• A. Notify the healthcare provider.
• B. Insert a new NG tube for feedings.
• C. Replace the NG tube to maintain gastric decompression.
• D. Leave the NG tube out as it may have been in long enough.

Correct answer: A

Rationale: The most appropriate action for the nurse to take in this situation is to notify the healthcare provider immediately. This is important as the removal of the NG tube can disrupt postoperative care, especially in terms of maintaining gastric decompression. Inserting a new NG tube without practitioner direction can be unsafe and is not within the nurse's scope of practice. Similarly, replacing the NG tube or leaving it out should be decided by the healthcare provider to ensure the infant's safety and appropriate postoperative care.

5. The nurse is caring for a child receiving chemotherapy with the following orders: Zantac 70 mg IV in normal saline 30 mL to infuse over 30 minutes. The nurse should set the infusion pump to deliver how many mL/hour?

• A. 60 mL/hour
• B. 45 mL/hour
• C. 30 mL/hour
• D. 15 mL/hour

Correct answer: A

Rationale: The correct answer is A: 60 mL/hour. The total volume to be infused is 30 mL over 30 minutes. To calculate the infusion rate in mL/hour, divide the total volume by the total time in hours. In this case, 30 mL / 0.5 hours = 60 mL/hour. Choice B, 45 mL/hour, is incorrect as it does not correspond to the calculated infusion rate. Choices C and D, 30 mL/hour and 15 mL/hour respectively, are also incorrect based on the calculation.

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