Nursing Elites

1. A child is hospitalized in acute renal failure and has a serum potassium greater than 7 mEq/L. What temporary measures that will produce a rapid but transient effect to reduce the potassium should the nurse expect to be prescribed? (Select all that apply.)

• A. Dialysis
• B. All below
• C. Sodium bicarbonate
• D. Glucose 50% and insulin

Correct answer: A

Rationale: Calcium gluconate, sodium bicarbonate, and glucose with insulin are used as temporary measures to rapidly reduce serum potassium levels. They help shift potassium into cells and stabilize the heart but do not remove potassium from the body like dialysis does.

2. What is the appropriate method for measuring the temperature of a 2-day-old neonate?

• A. Tympanic
• B. Oral
• C. Axillary
• D. Rectal

Correct answer: C

Rationale: For a 2-day-old neonate, the most suitable method to measure temperature is the axillary method. This approach is considered safe and appropriate for neonates, minimizing the risk of injury. Tympanic temperature measurement may not be as accurate in neonates due to their small ear canals. Oral temperature measurement is not recommended for neonates as they may not be able to hold a thermometer properly in their mouths. Rectal temperature measurement is invasive and carries a higher risk of injury and should be avoided unless absolutely necessary.

3. In assessing sexual maturity levels, which tool would you expect to use?

• A. Denver II Developmental Screening
• B. Tanner staging
• C. Antibody testing
• D. Nursing process

Correct answer: B

Rationale: The correct answer is B: Tanner staging. Tanner staging is a tool specifically used to assess sexual maturity in adolescents based on the development of secondary sexual characteristics. The Tanner scale ranges from stage 1 (prepubertal) to stage 5 (adult maturity). This tool helps healthcare providers evaluate the physical development and sexual maturation of individuals. Choice A, the Denver II Developmental Screening, is used to assess developmental milestones in children. Choice C, antibody testing, is a diagnostic tool used to detect the presence of specific antibodies in the blood. Choice D, the nursing process, is a systematic method that nurses use to deliver patient-centered care, involving assessment, diagnosis, planning, implementation, and evaluation.

4. Which actions by the nurse demonstrate clinical reasoning? (Select all that apply.)

• A. All below
• B. Considering alternative actions
• C. Using formal and informal thinking to gather data
• D. Giving deliberate thought to a patient's problem

Correct answer: A

Rationale: Clinical reasoning involves deliberate and thoughtful decision-making, considering alternatives, and using both formal and informal data gathering methods to provide optimum care.

5. The nurse is discussing development and play activities with the parent of a 2-month-old boy. Which statement by the parent would indicate a correct understanding of the teaching?

• A. I can give my baby a ball of yarn to pull apart or different textured fabrics to feel
• B. I can use a music box and soft mobiles as appropriate play activities for my baby
• C. I should introduce a cup and spoon or push-pull toys for my baby at this age
• D. I do not have to worry about appropriate play activities at this age

Correct answer: B

Rationale: At 2 months, infants are most stimulated by visual and auditory activities, such as a music box or soft mobiles. These activities help in sensory development and are appropriate for this age.

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