Nursing Elites

1. The healthcare provider notes that a child has lost 8 pounds after 4 days of hospitalization for acute glomerulonephritis. This is most likely the result of

• A. poor appetite
• B. increased potassium intake
• C. reduction of edema
• D. restriction to bed rest

Correct answer: C

Rationale: In acute glomerulonephritis, weight loss is most likely due to the reduction of edema. Edema is a common symptom of glomerulonephritis, which causes fluid retention and swelling in the body. As treatment progresses and the condition improves, the reduction of edema leads to weight loss. Choices A, B, and D are incorrect as they do not directly address the underlying pathophysiology of acute glomerulonephritis and its impact on weight loss.

2. What is an important nursing responsibility when a dysrhythmia is suspected?

• A. Order an immediate electrocardiogram
• B. Count the radial pulse every minute for five times
• C. Count the apical pulse for 1 full minute and compare the rate with the radial pulse rate
• D. Have someone else take the radial pulse simultaneously with the apical pulse

Correct answer: C

Rationale: When a dysrhythmia is suspected, it is important for nurses to count the apical pulse for a full minute and compare it with the radial pulse rate. This method helps in identifying dysrhythmias because discrepancies between the apical and radial pulse rates can indicate irregular heart rhythms. Option A is incorrect because ordering an immediate electrocardiogram may not always be feasible or necessary as a first step. Option B, counting the radial pulse multiple times, is less accurate than comparing the apical and radial pulse rates. Option D involves an unnecessary step of having another person take simultaneous pulses when the nurse can do it effectively alone.

3. A healthcare provider is assessing a child with suspected pneumonia. What clinical manifestation is the healthcare provider likely to observe?

• A. Cough
• B. Diarrhea
• C. Rash
• D. Vomiting

Correct answer: A

Rationale: When assessing a child with suspected pneumonia, a healthcare provider is likely to observe a cough as a common clinical manifestation. Pneumonia often presents with symptoms such as cough, fever, difficulty breathing, and chest pain. Choice B, diarrhea, is not typically associated with pneumonia. Choice C, rash, is not a common clinical manifestation of pneumonia. Choice D, vomiting, is also not a typical symptom of pneumonia. Therefore, the correct answer is A: Cough.

4. The nurse is caring for a 12-year-old boy with idiopathic thrombocytopenia. The nurse is providing discharge instructions about home care and safety recommendations to the boy and his parents. Which response indicates a need for further teaching?

• A. We should avoid aspirin and medications like ibuprofen.
• B. He can resume participation in football in 2 weeks.
• C. Swimming would be a great activity.
• D. Our son cannot take any antihistamines.

Correct answer: B

Rationale: Choice B indicates a need for further teaching because participation in contact sports like football should be avoided in children with idiopathic thrombocytopenia due to the increased risk of bleeding. Choices A, C, and D are correct. Avoiding aspirin and medications like ibuprofen helps prevent bleeding complications. Swimming is a safe physical activity that can be recommended. Antihistamines do not pose a significant risk in this case and can be used if needed.

5. The parent of a child who has received all of the primary immunizations asks the nurse which ones the child should receive before starting kindergarten. The nurse tells the parent that her child should receive boosters of:

• A. IPV, HepB, Td.
• B. DTaP, HepB, Td.
• C. MMR, DTaP, Hib.
• D. DTaP, IPV, MMR.

Correct answer: D

Rationale: The correct answer is D: DTaP, IPV, MMR. Before starting kindergarten, the child should receive boosters of DTaP, IPV, and MMR to ensure ongoing protection against diphtheria, tetanus, pertussis, polio, measles, mumps, and rubella. Choice A is incorrect because it includes HepB instead of MMR. Choice B is incorrect as it includes HepB instead of MMR and DTaP instead of IPV. Choice C is incorrect as it includes Hib instead of IPV.

Similar Questions