Nursing Elites

1. A child with a diagnosis of leukemia is receiving chemotherapy. What is the most important nursing intervention?

• A. Monitor for signs of infection
• B. Monitor for signs of bleeding
• C. Monitor for signs of dehydration
• D. Monitor for signs of pain

Correct answer: A

Rationale: The most important nursing intervention for a child with leukemia receiving chemotherapy is to monitor for signs of infection. Chemotherapy suppresses the immune system, putting the child at a higher risk of developing infections. Early detection and prompt treatment of infections are crucial to prevent complications and improve outcomes. Monitoring for signs of bleeding (choice B), dehydration (choice C), and pain (choice D) are also important aspects of care, but in this scenario, the priority is to prevent and manage infections due to the compromised immune system.

2. The nurse notes that a child has lost 8 pounds after 4 days of hospitalization for acute glomerulonephritis. This is most likely the result of

• A. poor appetite
• B. increased potassium intake
• C. reduction of edema
• D. restriction to bed rest

Correct answer: C

Rationale: The correct answer is C: reduction of edema. In acute glomerulonephritis, weight loss is often a result of the reduction of edema. Acute glomerulonephritis causes fluid retention and edema due to kidney inflammation. As the inflammation resolves with treatment, the kidneys can excrete excess fluid, leading to weight loss. Choices A, B, and D are incorrect. Poor appetite, increased potassium intake, and restriction to bed rest are not typically the primary reasons for weight loss in acute glomerulonephritis.

3. A 6-year-old with muscular dystrophy was recently injured falling out of bed at home. What intervention should the nurse suggest to prevent further injury?

• A. Recommend raising the bed's side rails when a caregiver is not present.
• B. Suggest a caregiver be present continuously to prevent falls from bed.
• C. Encourage the use of loose restraints while in bed.
• D. Recommend raising the bed's side rails throughout the day and night.

Correct answer: A

Rationale: In this scenario, the most appropriate intervention to prevent further injury is to raise the bed's side rails when a caregiver is not present. This measure helps in preventing falls without the need for constant supervision. Choice B is not practical as continuous caregiver presence may not always be feasible. Choice C is unsafe as loose restraints can pose a strangulation risk. Choice D does not address the need for intervention when a caregiver is absent, potentially leading to an increased risk of falls.

4. What should be taught to the child and parents about using a peak flow meter for a child diagnosed with asthma?

• A. Use the device before taking medication
• B. Use the device during asthma attacks
• C. Record the best of three attempts
• D. Use the device after eating

Correct answer: C

Rationale: The correct answer is to 'Record the best of three attempts.' This method provides an accurate measure of peak expiratory flow using a peak flow meter. By taking the best of three attempts, the child and parents can obtain a more reliable assessment of the child's lung function. Choices A, B, and D are incorrect because using the device before taking medication, during asthma attacks, or after eating does not ensure an accurate measurement of peak flow, which is essential for managing asthma effectively. Monitoring peak flow regularly and accurately can help in adjusting asthma treatment plans and assessing response to medications.

5. Which is the most appropriate nursing diagnosis for a child with acute glomerulonephritis?

• A. Risk for injury related to malignant process and treatment
• B. Fluid volume deficit related to excessive losses
• C. Fluid volume excess related to decreased plasma filtration
• D. Fluid volume excess related to fluid accumulation in tissues and third spaces

Correct answer: C

Rationale: The most appropriate nursing diagnosis for a child with acute glomerulonephritis is 'Fluid volume excess related to decreased plasma filtration.' Acute glomerulonephritis is characterized by inflammation in the glomeruli, leading to decreased plasma filtration and retention of fluid. This results in fluid volume excess rather than deficit, making choice C the correct answer. Choice A is incorrect because acute glomerulonephritis is not primarily associated with a malignant process. Choice B is incorrect as the condition typically presents with fluid volume excess rather than deficit. Choice D is also incorrect as fluid accumulation in tissues and third spaces is not a typical manifestation of acute glomerulonephritis.

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