Nursing Elites

1. What is considered fast breathing in a 13-month-old child if the respiratory rate (RR) exceeds which value?

• A. 40 breaths per minute
• B. 50 breaths per minute
• C. 60 breaths per minute
• D. 30 breaths per minute

Correct answer: C

Rationale: In the context of pediatric care, a respiratory rate of more than 60 breaths per minute in a child aged 13 months is considered fast breathing, hence option 'C' is correct. Options 'A', 'B', and 'D' are incorrect as they do not meet the specified criteria for fast breathing in a 13-month-old. Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, including monitoring respiratory rates, to ensure that interventions are appropriately targeted and outcomes are optimized.

2. Discharge plans of diabetic clients include injection site rotation. You should emphasize that the space between sites should be:

• A. 6.0 cm.
• B. 5.0 cm.
• C. 2.5 cm.
• D. 4.0 cm.

Correct answer: A

Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.

3. A client states they are taking greater than the recommended daily allowance of vitamin E to prevent cataracts. Which complication should the nurse educate the client as related to taking excessive amounts of vitamin E?

• A. Lung cancer
• B. Stroke
• C. Diarrhea
• D. Liver damage

Correct answer: B

Rationale: The correct answer is B: Stroke. High doses of vitamin E supplements have been associated with an increased risk of hemorrhagic stroke due to its blood-thinning properties. Option A, lung cancer, is not a known complication of excessive vitamin E intake. Option C, diarrhea, is more commonly associated with excessive intake of other vitamins or minerals. Option D, liver damage, is not a commonly reported complication of vitamin E overdose.

4. What health instruction will enhance regulation of a colostomy (defecation) of clients?

• A. Irrigate after lunch everyday
• B. Eat fruits and vegetables in all three meals
• C. Eat balanced meals at regular intervals
• D. Restrict exercise to walking only

Correct answer: A

Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.

5. A client receiving total parenteral nutrition (TPN) suddenly develops tremors, dizziness, and diaphoresis. The client said, 'I feel weak and the bag was empty.' Which is the most likely complication the client is currently experiencing?

• A. Fluid volume overload
• B. Sepsis
• C. Hyperglycemia
• D. Hypoglycemia

Correct answer: D

Rationale: The client experiencing tremors, dizziness, diaphoresis, weakness, and stating that the TPN bag is empty is likely experiencing hypoglycemia. Hypoglycemia can occur when the TPN infusion suddenly stops, leading to a rapid drop in blood sugar levels. Symptoms of hypoglycemia include tremors, dizziness, diaphoresis, and weakness. Choices A, B, and C are incorrect as the symptoms presented are more consistent with hypoglycemia rather than fluid volume overload, sepsis, or hyperglycemia.

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