Nursing Elites

1. A 4-year-old child with acute glomerulonephritis is admitted to the hospital. The nurse identifies which client problem in the plan of care as the priority?

• A. Infection related to hypertension
• B. Injury related to loss of blood in urine
• C. Excessive fluid volume related to decreased plasma filtration
• D. Retarded growth and development related to a chronic disease

Correct answer: C

Rationale: In acute glomerulonephritis, the child experiences excessive accumulation of water and retention of sodium, leading to circulatory congestion and edema. Excessive fluid volume is a primary concern due to the disease process. Hypertension and infection are not directly related to acute glomerulonephritis; therefore, they are not the priority client problems. While hematuria (blood in urine) may occur, it typically does not lead to significant injury that takes precedence over excessive fluid volume. Acute glomerulonephritis is an acute condition, not chronic; therefore, retarded growth and development related to a chronic disease is not the priority issue. With proper management, most children recover completely without long-term growth and development issues.

2. A nurse in the emergency department is observing a 4-year-old child for signs of increased intracranial pressure after a fall from a bicycle, resulting in head trauma. Which of the following signs or symptoms would be cause for concern?

• A. Bulging anterior fontanel
• B. Repeated vomiting
• C. Signs of sleepiness at 10 PM
• D. Inability to read short words from a distance of 18 inches

Correct answer: B

Rationale: Increased intracranial pressure after head trauma can lead to serious complications. Repeated vomiting is a concerning sign as it can indicate stimulation of the vomiting center within the brainstem due to increased pressure. This can be an early indicator of raised intracranial pressure and the need for urgent medical intervention. Bulging anterior fontanel may not be immediately apparent in a 4-year-old child and is more common in infants. Signs of sleepiness at a particular time of day are not specific to increased intracranial pressure. Inability to read short words from a distance of 18 inches may indicate vision problems but is not directly related to intracranial pressure.

3. To palpate the liver during a head-to-toe physical assessment, the nurse should

• A. put pressure on the biopsy site using a sandbag
• B. elevate the head of the bed to facilitate breathing
• C. place the patient on the right side with the bed flat
• D. check the patient's post-biopsy coagulation studies

Correct answer: C

Rationale: To palpate the liver effectively during a head-to-toe physical assessment, the patient should be positioned on the right side with the bed flat. This position helps to splint the biopsy site and allows for proper palpation of the liver. Elevating the head of the bed has no direct relevance to palpating the liver. Checking coagulation studies is done before the biopsy and is unrelated to palpation. Putting pressure on the biopsy site using a sandbag is not an appropriate way to facilitate liver palpation as it does not provide the necessary support and stabilization needed for the procedure.

4. A serum potassium level of 3.2 mEq/L (3.2 mmol/L) is reported for a patient with cirrhosis who has scheduled doses of spironolactone (Aldactone) and furosemide (Lasix) due. Which action should the nurse take?

• A. Administer both drugs.
• B. Administer the spironolactone.
• C. Withhold the spironolactone and administer the furosemide.
• D. Withhold both drugs until discussed with the healthcare provider.

Correct answer: B

Rationale: A serum potassium level of 3.2 mEq/L is low (hypokalemia), which can be concerning in a patient with cirrhosis who is already at risk for electrolyte imbalances. Spironolactone is a potassium-sparing diuretic that can help increase the patient's potassium level and correct the hypokalemia. Therefore, the appropriate action for the nurse to take in this scenario is to administer the spironolactone. Withholding the spironolactone could further lower the potassium level. Furosemide, on the other hand, is a loop diuretic that can lead to potassium loss and worsen hypokalemia; hence, it should be withheld until the nurse discusses the situation with the healthcare provider. While the healthcare provider should be informed about the low potassium value, immediate administration of spironolactone is necessary to address the hypokalemia in this patient population.

5. When caring for a patient hospitalized with active tuberculosis (TB), the nurse observes a student nurse who is assigned to take care of the patient. Which action, if performed by the student nurse, would require an intervention by the nurse?

• A. The patient is offered a tissue from the box at the bedside.
• B. A surgical face mask is applied before visiting the patient.
• C. A snack is brought to the patient from the unit refrigerator.
• D. Hand washing is performed before entering the patient's room.

Correct answer: B

Rationale: When caring for a patient with active tuberculosis (TB), it is crucial to use a high-efficiency particulate-absorbing (HEPA) mask instead of a standard surgical mask when entering the patient's room, as a HEPA mask can filter out 100% of small airborne particles, reducing the risk of transmission. Therefore, if the student nurse applies only a surgical face mask before visiting the patient, this action would require intervention by the nurse to ensure the appropriate protective equipment is used. Hand washing before entering the patient's room is essential to prevent the spread of infection and is a correct action. Bringing a snack to the patient from the unit refrigerator is appropriate and helps address potential issues with anorexia and weight loss in patients with TB. While hand washing after handling a tissue used by the patient is necessary, no special precautions are required when offering the patient an unused tissue.

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