Nursing Elites

1. What action should the nurse implement when the infusion of chemotherapy via an implanted medication port is complete for a 16-year-old with acute myelocytic leukemia at the outpatient oncology clinic?

• A. Administer Zofran
• B. Obtain blood samples for RBCs, WBCs, and platelets
• C. Flush mediport with saline and heparin solution
• D. Initiate an infusion of normal saline

Correct answer: C

Rationale: The correct action for the nurse to implement when the chemotherapy infusion is complete is to flush the mediport with saline and heparin solution. This process helps prevent clotting and ensures the patency of the port, which is essential for future medication administrations and blood draws. Administering Zofran (Choice A) is not necessary after completing the chemotherapy infusion. Obtaining blood samples (Choice B) for RBCs, WBCs, and platelets is important but not the immediate action after completing the infusion. Initiating an infusion of normal saline (Choice D) is not required unless there is a specific indication for it.

2. What information should be reinforced with the parents about introducing solid foods to their infant?

• A. Begin with one tablespoon of the food.
• B. Introduce each food 4 to 7 days apart.
• C. Mix the new food with rice cereal.
• D. Remove foods when the infant refuses them.

Correct answer: B

Rationale: The correct answer is B. Introducing solid foods 4 to 7 days apart is crucial as it allows time to identify any allergic reactions or intolerances to specific foods. This gradual introduction helps parents monitor their infant's response to new foods and pinpoint any potential issues, ensuring the infant's safety and well-being. Choices A, C, and D are incorrect because starting with one tablespoon of the food, mixing new food with rice cereal, and removing foods when the infant refuses them are not recommended practices for introducing solid foods to infants.

3. A child with cystic fibrosis is being discharged home with pancreatic enzyme replacement therapy. What information should the practical nurse reinforce with the parents?

• A. Give the enzymes after meals.
• B. Mix the enzymes with hot food or drinks.
• C. Enzymes should be taken before or with meals.
• D. Avoid giving enzymes with any food or drink.

Correct answer: C

Rationale: The correct answer is C: 'Enzymes should be taken before or with meals.' Pancreatic enzymes should be taken before or with meals to assist with digestion in children with cystic fibrosis. This timing helps maximize the effectiveness of the enzymes in breaking down nutrients from food. Giving the enzymes after meals (choice A) may not provide the necessary support for digestion. Mixing the enzymes with hot food or drinks (choice B) is not recommended as it may affect the enzymes' efficacy. Avoiding giving enzymes with any food or drink (choice D) is incorrect as enzymes need to be taken in conjunction with meals to aid in digestion.

4. A 16-year-old adolescent is admitted to the hospital with a diagnosis of meningitis. The nurse notes that the client has a severe headache and photophobia. What is the nurse’s priority action?

• A. Administer prescribed pain medication
• B. Place the client in a dark, quiet room
• C. Notify the healthcare provider
• D. Encourage the client to rest

Correct answer: B

Rationale: The priority action for the nurse when a client with meningitis presents with a severe headache and photophobia is to place the client in a dark, quiet room. This intervention helps reduce stimuli that can exacerbate symptoms such as headache and photophobia. Creating a calm environment can provide relief and promote comfort for the client while also supporting their recovery. Administering pain medication may be necessary but ensuring a suitable environment takes precedence. Notifying the healthcare provider is important but is not the immediate priority. Encouraging rest is beneficial, but creating an appropriate environment to alleviate symptoms is the initial essential step.

5. In a hospitalized child receiving IV fluids for dehydration, what is the best indicator that the child’s dehydration is improving?

• A. The child’s urine output increases
• B. The child’s skin turgor is normal
• C. The child’s weight increases
• D. The child’s vital signs are stable

Correct answer: A

Rationale: An increase in urine output is a reliable indicator of improving dehydration in a child. It signifies that the kidneys are functioning better, helping to restore fluid balance in the body. Monitoring urine output is crucial in assessing hydration status and response to treatment. Choices B, C, and D are not the best indicators of improving dehydration. Normal skin turgor is helpful but may not change immediately with improving hydration. Weight increase may reflect retained fluids rather than improved hydration status. Stable vital signs are important but may not always indicate improving dehydration.

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