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. To prevent unnecessary hypoxia during suctioning of a tracheostomy, what must the nurse do?

• A. Apply suction for no more than 10 seconds
• B. Maintain sterile technique
• C. Lubricate 3 to 4 inches of the catheter tip
• D. Withdraw catheter in a circular motion

Correct answer: A

Rationale: The correct answer is to apply suction for no more than 10 seconds. Prolonged suctioning can lead to hypoxia, so it is essential to limit the suctioning time. Maintaining sterile technique (choice B) is important to prevent infections but is not directly related to preventing hypoxia during suctioning. Lubricating the catheter tip (choice C) helps with insertion but does not specifically address hypoxia prevention. Withdrawing the catheter in a circular motion (choice D) is not a standard practice during tracheostomy suctioning and does not help prevent hypoxia.

3. A client with gastroesophageal reflux disease (GERD) is prescribed omeprazole. What is the primary purpose of this medication?

• A. Coat the lining of the stomach
• B. Neutralize stomach acid
• C. Promote gastric motility
• D. Reduce gastric acid secretion

Correct answer: D

Rationale: The correct answer is D: Reduce gastric acid secretion. Omeprazole is a proton pump inhibitor that works by reducing the production of gastric acid in the stomach. This helps in managing GERD by decreasing the acidity levels in the stomach. Choice A is incorrect because omeprazole does not coat the lining of the stomach. Choice B is incorrect as omeprazole does not neutralize stomach acid but rather reduces its production. Choice C is incorrect because omeprazole does not promote gastric motility; instead, it acts on acid secretion.

4. A client's chest tube insertion site has crepitus (crackling sensation) upon palpation. What is the nurse's next step?

• A. Apply a pressure dressing to the chest tube site.
• B. Administer an oral antihistamine.
• C. Assess the client for allergies to cleaning agents.
• D. Measure the area of swelling and crackling.

Correct answer: D

Rationale: The correct next step for the nurse is to measure the area of crepitus. Crepitus indicates subcutaneous emphysema, which is a serious condition requiring monitoring. Applying a pressure dressing (Choice A) could worsen the condition by trapping air under the skin. Administering an oral antihistamine (Choice B) is not indicated for crepitus. Assessing for allergies to cleaning agents (Choice C) is not the priority when dealing with crepitus and subcutaneous emphysema.

5. The nurse is caring for a 24-month-old toddler who has sensory sensitivity, difficulty engaging in social interactions, and has not yet spoken two-word phrases. Which assessment should the nurse administer?

• A. Peabody Picture Vocabulary Test
• B. The Modified Checklist for Autism in Toddlers (M-CHAT)
• C. Wechsler Preschool and Primary Scale of Intelligence
• D. Denver Developmental Screening Test

Correct answer: B

Rationale: The Modified Checklist for Autism in Toddlers (M-CHAT) is specifically designed to screen for autism spectrum disorders in young children. It is appropriate for this child, given the signs of social and communication delays. The Peabody Picture Vocabulary Test (Choice A) assesses receptive vocabulary and may not capture the social and communication aspects seen in autism. The Wechsler Preschool and Primary Scale of Intelligence (Choice C) measures cognitive ability and may not address the social and communication delays. The Denver Developmental Screening Test (Choice D) is a broad developmental assessment tool, but the M-CHAT is more specific to screening for autism in this case.

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