Nursing Elites

1. Which is the appropriate intervention when providing care to a child diagnosed with nephrotic syndrome, who is edematous and on bed rest?

• A. Monitor blood pressure every 30 minutes.
• B. Reposition every 2 hours.
• C. Limit visitors.
• D. Encourage fluids.

Correct answer: B

Rationale: Repositioning every 2 hours is crucial in preventing skin breakdown in an edematous child on bed rest. This intervention helps redistribute pressure and maintain skin integrity, reducing the risk of pressure ulcers. It is an essential part of care for patients with limited mobility to ensure their comfort and prevent complications related to immobility.

2. The patient is receiving a heparin infusion for the treatment of pulmonary embolism. Which assessment finding is most likely related to an adverse effect of heparin?

• A. HR of 60 bpm
• B. BP of 160/88
• C. Discolored urine
• D. Inspiratory wheezing

Correct answer: C

Rationale: The primary and most serious adverse effect of heparin is bleeding. However, discolored urine can indicate bleeding into the urinary tract, which is a potential adverse effect of heparin therapy. While changes in heart rate (HR) and blood pressure (BP) can occur due to various reasons, discolored urine specifically points towards a potential adverse effect related to heparin therapy.

3. A school-age child is 4 hours postoperative following perforated appendicitis repair. Which of the following actions should the nurse take?

• A. Maintain the child on a clear liquid diet for 48 hours.
• B. Administer antibiotics for 7 days.
• C. Apply warm compresses to the surgical site every 4 hours.
• D. Keep the child on NPO status for 24 hours.

Correct answer: B

Rationale: Administering antibiotics for 7 days is essential postoperatively to prevent infections and complications in a child who underwent perforated appendicitis repair. This helps in reducing the risk of secondary infections and promoting healing. Clear liquid diets, warm compresses, and prolonged fasting are not the primary interventions indicated in this scenario.

4. Which principle does not follow neuromaturational theory?

• A. The sequence and rate of motor development are consistent among infants
• B. Movement emerges from an interaction and cooperation of many systems
• C. Movement progresses from primitive reflexes to voluntary control
• D. Low-level skills are prerequisites for certain high-level skills

Correct answer: B

Rationale: Neuromaturational theory emphasizes that motor development progresses in a predictable sequence and rate, starting from primitive reflexes to voluntary control. It also states that low-level skills are foundational for higher-level skills. However, the theory does not support the idea that movement solely emerges from an interaction and cooperation of many systems, as it focuses more on the hierarchical development of motor skills.

5. A nurse is teaching a parent of a child who has asthma. Which of the following instructions should the nurse include?

• A. Use a peak flow meter daily.
• B. Administer the medication with meals.
• C. Provide a low-carbohydrate diet.
• D. Limit exposure to cold air.

Correct answer: A

Rationale:

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