Nursing Elites

1. A 5-week-old infant with hypertrophic pyloric stenosis has developed projectile vomiting over the last two weeks. Which intervention should the nurse plan to implement?

• A. Instruct the mother to give sugar water only.
• B. Offer the infant oral rehydration every 2 hours.
• C. Provide Pedialyte feedings via nasogastric tube.
• D. Maintain intravenous fluid therapy.

Correct answer: D

Rationale: The correct intervention for a 5-week-old infant with hypertrophic pyloric stenosis presenting with projectile vomiting is to maintain intravenous fluid therapy. This is essential to maintain hydration before surgery. Instructing the mother to give sugar water only (Choice A) is inadequate and does not address the need for proper hydration. Offering oral rehydration every 2 hours (Choice B) may not be effective in cases of severe vomiting and could lead to further fluid loss. Providing Pedialyte feedings via nasogastric tube (Choice C) is an option, but in severe cases, intravenous fluid therapy is more effective in ensuring hydration and electrolyte balance.

2. A client is admitted with a suspected gastrointestinal bleed. What assessment finding requires immediate intervention?

• A. Bright red blood in the vomit.
• B. Elevated blood pressure and heart rate.
• C. Coffee ground emesis.
• D. Dark, tarry stools.

Correct answer: D

Rationale: Dark, tarry stools indicate the presence of digested blood in the gastrointestinal tract, signifying a higher gastrointestinal bleed. This finding requires immediate intervention due to the potential severity of the bleed. Bright red blood in the vomit may indicate active bleeding but is not as concerning as digested blood. Elevated blood pressure and heart rate are common responses to bleeding but do not provide direct evidence of the source or severity of the bleed. Coffee ground emesis is indicative of partially digested blood and is a concern but not as urgent as dark, tarry stools.

3. A client reports gastrointestinal upset after taking oral tetracycline. Which snack should the nurse recommend?

• A. Yogurt with fruit
• B. Toast with jelly
• C. Crackers with peanut butter
• D. Oatmeal with raisins

Correct answer: B

Rationale: The correct answer is B: Toast with jelly. Tetracycline can cause gastrointestinal upset when taken with dairy products. Yogurt with fruit (Choice A) contains dairy, which can worsen the gastrointestinal upset. Crackers with peanut butter (Choice C) and oatmeal with raisins (Choice D) are also not the best choices as they may not be gentle enough on the stomach. Toast with jelly is a simple snack that does not contain dairy and is less likely to exacerbate the gastrointestinal upset.

4. A client with a seizure disorder is prescribed phenytoin. What is the most important teaching the nurse should provide?

• A. Take phenytoin with antacids to reduce stomach upset.
• B. Maintain a consistent dosing schedule to prevent seizures.
• C. Monitor for excessive drowsiness and dizziness.
• D. Take the medication at bedtime to reduce seizure risk.

Correct answer: B

Rationale: The most important teaching the nurse should provide to a client prescribed phenytoin is to maintain a consistent dosing schedule to prevent seizures. Phenytoin is an antiepileptic drug, and missing doses can increase the risk of seizures. Option A is incorrect because antacids can interact with phenytoin and reduce its absorption. Option C is important but not the most critical teaching as compared to maintaining a consistent dosing schedule. Option D is incorrect because the timing of phenytoin administration should be consistent rather than specifically at bedtime.

5. The nurse is instructing a 65-year-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to

• A. Exercise doing weight-bearing activities
• B. Exercise to reduce weight
• C. Avoid exercise activities that increase the risk of fracture
• D. Exercise to strengthen muscles and thereby protect bones

Correct answer: A

Rationale: Weight-bearing exercises are crucial in managing osteoporosis as they help strengthen bones. Choice A is the correct answer because weight-bearing activities, such as walking, dancing, or weight training, help stimulate bone formation and strengthen bones, which is essential in managing osteoporosis. Choice B is incorrect as the primary focus should be on the type of exercise rather than weight reduction. Choice C is incorrect because avoiding exercise altogether can lead to further bone density loss, and it is important to engage in safe weight-bearing activities. Choice D is incorrect as the primary goal of exercise in osteoporosis is to improve bone density through weight-bearing activities.

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