Nursing Elites

1. A 7-year-old child is admitted to the hospital with nephrotic syndrome. The nurse notes that the child has gained 3 pounds in the past 24 hours. What should the nurse do first?

• A. Administer a diuretic as prescribed
• B. Restrict the child’s fluid intake
• C. Notify the healthcare provider
• D. Measure the child’s abdominal girth

Correct answer: C

Rationale: In a child with nephrotic syndrome experiencing sudden weight gain, the priority action for the nurse is to notify the healthcare provider. This weight gain could indicate worsening edema or fluid retention, necessitating immediate medical evaluation and intervention. The healthcare provider can conduct a comprehensive assessment, order necessary tests, and adjust the treatment plan accordingly. Administering a diuretic, restricting fluid intake, or measuring abdominal girth should not be initiated without healthcare provider consultation to ensure appropriate management of the child's condition.

2. When caring for a 5-year-old child with a history of seizures who suddenly begins to have a tonic-clonic seizure, what should the nurse do first?

• A. Administer oxygen
• B. Insert an oral airway
• C. Turn the child to the side
• D. Start an IV line

Correct answer: C

Rationale: During a tonic-clonic seizure, the priority action is to turn the child to the side. This helps maintain an open airway and prevents aspiration of secretions or vomitus. It also helps in keeping the airway clear and promotes safety during the seizure episode. Administering oxygen, inserting an oral airway, and starting an IV line are important interventions but should follow the initial step of positioning the child to prevent airway obstruction.

3. A 4-year-old child with a history of asthma is brought to the clinic with a complaint of cough and wheezing. The nurse notes that the child has been using a rescue inhaler more frequently over the past week. What should the nurse do next?

• A. Review the child’s asthma action plan
• B. Administer a dose of the rescue inhaler
• C. Instruct the parents to increase the dose of the controller medication
• D. Schedule a follow-up appointment in one week

Correct answer: A

Rationale: In this scenario, the best course of action for the nurse is to review the child's asthma action plan. By doing so, the nurse can assess the current asthma management, ensure that the child is using the rescue inhaler correctly, and make any necessary adjustments to the treatment plan. Reviewing the asthma action plan helps in identifying triggers, proper use of medications, and when to seek medical help. Administering a dose of the rescue inhaler without assessing the current management plan may not address the underlying issue. Instructing the parents to increase the dose of the controller medication without proper evaluation can lead to inappropriate medication adjustments. Scheduling a follow-up appointment in one week is not the immediate action needed to address the child's current symptoms.

4. The nurse is caring for a 4-year-old child who has been diagnosed with measles. Which intervention should the nurse implement to prevent the spread of infection?

• A. Administer antipyretics as prescribed
• B. Place the child in airborne isolation
• C. Encourage fluid intake
• D. Teach the parents about hand hygiene

Correct answer: B

Rationale: Measles is an airborne infection, so placing the child in airborne isolation is crucial to prevent the spread of the virus to others. Airborne isolation precautions help contain infectious respiratory droplets and reduce the risk of transmission to healthcare workers, other patients, and visitors. Administering antipyretics, encouraging fluid intake, and teaching parents about hand hygiene are important aspects of care but do not directly address the prevention of the spread of measles, which requires airborne precautions.

5. What information should the nurse provide to parents of a 3-year-old boy with Duchenne muscular dystrophy who inquire about the disease and future children?

• A. This is an inherited X-linked recessive disorder, which primarily affects male children in the family
• B. The striated muscle groups of males can be impacted by a lack of the protein dystrophin in their mothers
• C. The male infant had a viral infection that went unnoticed and untreated so muscle damage was incurred
• D. Birth trauma with a breech vaginal birth causes damage to the spinal cord, thus weakening the muscles

Correct answer: A

Rationale: Duchenne muscular dystrophy is an X-linked recessive disorder caused by mutations in the DMD gene on the X chromosome. This disorder primarily affects males because they have one X chromosome, inherited from their mothers, who may be carriers of the mutated gene. Females have two X chromosomes, providing a protective effect as the normal gene on one X chromosome can compensate for the mutated gene on the other. Therefore, the nurse should explain to the parents that Duchenne muscular dystrophy is an inherited X-linked recessive disorder, which is why their son has the disease and why there is a risk of passing it on to future sons. Choice B is incorrect as it inaccurately implies that the lack of dystrophin in mothers impacts their sons' muscle groups. Choice C is incorrect as it suggests a viral infection caused the muscle damage, which is not the case with Duchenne muscular dystrophy. Choice D is incorrect as it attributes the muscle weakness to birth trauma instead of the genetic nature of the disorder.

Similar Questions