Nursing Elites

1. What is the most important assessment for a nurse to conduct on a child diagnosed with intussusception?

• A. Monitor for signs of infection.
• B. Measure abdominal girth and monitor for pain.
• C. Check for bowel movement and changes in stool.
• D. Assess hydration status and monitor urine output.

Correct answer: C

Rationale: The correct answer is C: 'Check for bowel movement and changes in stool.' Intussusception can cause obstruction in the bowel, leading to symptoms like abdominal pain, vomiting, and 'currant jelly' stools. Monitoring for changes in bowel movement, especially the passage of 'currant jelly' stools, is crucial for early detection of worsening conditions. Choices A, B, and D are important assessments in pediatric care but are not as specific or crucial as checking for changes in bowel movement in a child diagnosed with intussusception.

2. A child has a nosebleed (epistaxis) while playing soccer. In what position should the nurse place the child?

• A. Position the child lying flat and apply pressure to the bridge of the nose.
• B. Position the child sitting up and leaning forward.
• C. Have the child tilt the head back and pinch the nose.
• D. Position the child lying on their side and apply ice to the nose.

Correct answer: B

Rationale: The correct answer is to position the child sitting up and leaning forward. This position helps prevent blood from flowing down the throat, reducing the risk of choking or vomiting. Choice A is incorrect because lying flat can cause blood to flow down the throat. Choice C is wrong as tilting the head back may lead to blood entering the throat. Choice D is also incorrect as applying ice is not recommended for nosebleeds and lying on the side may not prevent blood from flowing down the throat.

3. The nurse observes that a client’s wrist restraint is secured to the side rail of the bed. What action should the nurse take?

• A. Ensure that the restraint is snug against the client’s wrist.
• B. Reposition the restraint tie onto the bedframe.
• C. Double knot the restraint to ensure safety.
• D. Leave the restraint in place and notify the healthcare provider.

Correct answer: B

Rationale: The correct action for the nurse to take is to reposition the restraint tie onto the bedframe. Restraints should always be secured to the bedframe, not the side rails, to prevent injury to the client in case the bed is adjusted. Choice A is incorrect because the issue is with the attachment point, not the snugness of the restraint. Choice C is incorrect as double knotting the restraint does not address the incorrect attachment point. Choice D is incorrect as the nurse should not leave the restraint in the wrong position; instead, it should be moved to the correct location on the bedframe.

4. A client with osteoarthritis is prescribed acetaminophen. What is the most important teaching the nurse should provide?

• A. Take the medication with food to improve absorption.
• B. Avoid taking other pain medications to prevent liver damage.
• C. Take acetaminophen on an empty stomach to prevent stomach upset.
• D. Monitor liver function tests regularly to detect any liver damage.

Correct answer: B

Rationale: The correct answer is B. Acetaminophen can cause liver damage if taken in excessive amounts or in combination with other medications containing acetaminophen. Clients should be advised to avoid other pain medications to prevent liver toxicity. Choice A is incorrect because acetaminophen is usually taken with or without food, not specifically on an empty stomach. Choice C is incorrect because taking acetaminophen with food can help prevent stomach upset. Choice D is incorrect because while monitoring liver function tests is important for long-term acetaminophen use, the most crucial teaching is to avoid other pain medications to prevent liver damage.

5. A client with chronic kidney disease has a potassium level of 6.2 mEq/L. Which intervention should the nurse implement?

• A. Encourage the client to eat foods rich in potassium
• B. Administer a potassium-sparing diuretic
• C. Administer a potassium-binding medication
• D. Hold all medications containing potassium

Correct answer: C

Rationale: A potassium level of 6.2 mEq/L indicates hyperkalemia, which is dangerous and requires immediate treatment. Administering a potassium-binding medication will help lower potassium levels and prevent life-threatening complications.

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