Nursing Elites

1. What is the priority nursing intervention for a child admitted to the hospital with a diagnosis of acute glomerulonephritis?

• A. Monitoring for hypertension
• B. Providing pain relief
• C. Restricting fluid intake
• D. Encouraging fluid intake

Correct answer: A

Rationale: The priority nursing intervention for a child with acute glomerulonephritis is monitoring for hypertension. Acute glomerulonephritis involves inflammation of the kidney's glomeruli, leading to impaired kidney function. Hypertension is a common complication due to fluid retention and increased renin-angiotensin system activity. Monitoring for hypertension is crucial for early detection and management to prevent further kidney damage and complications. Providing pain relief (Choice B) may be required for discomfort but is not the priority. Restricting fluid intake (Choice C) may be necessary in some kidney diseases, but in acute glomerulonephritis, the focus is on monitoring and managing hypertension. Encouraging fluid intake (Choice D) is inappropriate as it can exacerbate fluid overload and hypertension in acute glomerulonephritis.

2. When teaching the parents of a child with a diagnosis of type 1 diabetes mellitus about insulin administration, what should the nurse emphasize?

• A. Rotate injection sites
• B. Administer insulin before meals
• C. Store insulin in the refrigerator
• D. Administer insulin at bedtime

Correct answer: A

Rationale: The correct answer is to rotate injection sites. This practice helps prevent lipodystrophy, a localized loss of fat tissue that can affect insulin absorption. By rotating sites, the child can avoid developing lumps or indentations in the skin where insulin is repeatedly injected. Administering insulin before meals (choice B) may be necessary for certain types of insulin but is not the priority when teaching about insulin administration. Storing insulin in the refrigerator (choice C) is important for maintaining its potency, but it is not the primary emphasis when teaching about insulin administration. Administering insulin at bedtime (choice D) may be necessary based on the child's insulin regimen but is not the primary consideration for teaching injection techniques and site rotation.

3. Before starting kindergarten, the child should receive boosters of which primary immunizations to ensure ongoing protection?

• A. IPV, HepB, Td.
• B. DTaP, HepB, Td.
• C. MMR, DTaP, Hib.
• D. DTaP, IPV, MMR.

Correct answer: D

Rationale: Before starting kindergarten, the child should receive boosters of DTaP, IPV, and MMR. DTaP provides protection against diphtheria, tetanus, and pertussis, IPV protects against polio, and MMR immunization covers measles, mumps, and rubella. These boosters are essential to maintain immunity and protect the child from these diseases as they enter school. Choices A, B, and C are incorrect because they do not include the recommended boosters for kindergarten entry and may leave the child susceptible to certain infections.

4. At 7 AM, a nurse receives the information that an adolescent with diabetes has a 6:30 AM fasting blood glucose level of 180 mg/dL. What is the priority nursing action at this time?

• A. Encourage the adolescent to start exercising.
• B. Ask the adolescent to obtain an immediate glucometer reading.
• C. Inform the adolescent that a complex carbohydrate such as cheese should be eaten.
• D. Tell the adolescent that the prescribed dose of rapid acting insulin should be administered.

Correct answer: D

Rationale: Rapid acting insulin will help lower the elevated blood glucose level quickly.

5. A child with a diagnosis of cystic fibrosis is under the care of a nurse. What is the priority nursing intervention?

• A. Administering pancreatic enzymes
• B. Providing respiratory therapy
• C. Encouraging physical activity
• D. Encouraging frequent handwashing

Correct answer: A

Rationale: The priority nursing intervention for a child with cystic fibrosis is administering pancreatic enzymes. This is crucial for managing the condition as it helps in proper digestion of nutrients. Providing respiratory therapy and encouraging physical activity are important aspects of care for cystic fibrosis, but administering pancreatic enzymes takes precedence due to its direct impact on the child's ability to digest and absorb essential nutrients. Encouraging frequent handwashing is a good practice for infection control but is not the priority intervention in this scenario.

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