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. The nurse is providing care for a client with heart failure who is prescribed furosemide. Which laboratory value should the nurse monitor closely?

• A. Calcium level
• B. Sodium level
• C. Magnesium level
• D. Potassium level

Correct answer: D

Rationale: The correct answer is D: Potassium level. Furosemide is a loop diuretic that can cause potassium loss, leading to hypokalemia. Monitoring potassium levels is crucial to prevent complications such as cardiac arrhythmias. While calcium, sodium, and magnesium levels are important in various conditions and treatments, they are not the primary electrolyte affected by furosemide.

3. A client with a history of adrenal insufficiency is admitted with acute adrenal crisis. The client complains of nausea and joint pain, vital signs show a temperature of 102°F, heart rate of 138, and blood pressure of 80/60. Which intervention should the nurse implement first?

• A. Obtain an analgesic prescription.
• B. Infuse an intravenous fluid bolus.
• C. Administer PRN oral antipyretic.
• D. Cover the client with a cooling blanket.

Correct answer: B

Rationale: In acute adrenal crisis, the priority intervention is to infuse an intravenous fluid bolus to address the hypotension (blood pressure of 80/60) and help stabilize the client's condition. Adequate fluid volume is crucial in managing adrenal insufficiency crisis. Options A, C, and D do not directly address the hypotension and fluid volume depletion that are critical in this situation. Analgesics, antipyretics, and cooling blankets may be considered later, but the immediate focus should be on fluid resuscitation.

4. A client with cirrhosis is at risk for bleeding due to impaired liver function. Which laboratory result is the most important to monitor?

• A. Blood urea nitrogen (BUN)
• B. Prothrombin time (PT)
• C. Aspartate aminotransferase (AST)
• D. Serum albumin

Correct answer: B

Rationale: Prothrombin time (PT) measures the time it takes for blood to clot and is a critical indicator of bleeding risk in clients with liver dysfunction. Impaired liver function reduces clotting factor production, leading to an increased PT, which requires close monitoring. Monitoring BUN (Choice A) is more indicative of kidney function, not clotting ability. Aspartate aminotransferase (AST) (Choice C) and serum albumin (Choice D) are important indicators of liver function, but they do not directly assess the client's bleeding risk.

5. Which documentation indicates that activities to prevent postoperative venous stasis were performed correctly?

• A. Antiembolism stockings on, leg exercises performed hourly.
• B. Antiembolism stockings removed hourly during leg exercises.
• C. Leg exercises not performed due to antiembolism hose.
• D. Client demonstrates ability to move extremities well.

Correct answer: A

Rationale: The correct answer is A: 'Antiembolism stockings on, leg exercises performed hourly.' This documentation indicates the correct performance of activities to prevent postoperative venous stasis, as both components are crucial for prevention. Choice B is incorrect because removing stockings hourly is not recommended. Choice C is incorrect as leg exercises should be performed despite wearing antiembolism stockings. Choice D is incorrect as demonstrating the ability to move extremities well does not specifically address the prevention of venous stasis.

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