Nursing Elites

1. A child with glomerulonephritis is admitted in the acute edematous phase. Based on this diagnosis, which nursing intervention should the PN plan to include in the child's plan of care?

• A. Recommend parents bring favorite snacks
• B. Encourage ambulation daily to the playroom
• C. Measure blood pressure every 4 to 6 hours
• D. Offer a selection of fresh fruit for each meal

Correct answer: C

Rationale: The correct answer is to measure blood pressure every 4 to 6 hours. In glomerulonephritis, monitoring blood pressure is crucial as hypertension is a common complication. This helps in assessing the child's condition and response to treatment. Choice A, recommending parents bring favorite snacks, is not related to managing glomerulonephritis. Choice B, encouraging ambulation daily to the playroom, may not be appropriate during the acute edematous phase when the child may be experiencing fluid overload. Choice D, offering a selection of fresh fruit for each meal, is not directly relevant to managing the complications of glomerulonephritis.

2. While caring for a client with an AV fistula in the left forearm, the nurse observed a palpable buzzing sensation over the fistula. What action should the nurse take?

• A. Loosen the dressing of the fistula
• B. Report the presence of a bounding pulse
• C. Document that the fistula is intact
• D. Apply gentle pressure over the site

Correct answer: C

Rationale: The correct answer is C: Document that the fistula is intact. The palpable buzzing sensation (known as a thrill) over the AV fistula indicates proper functioning. It is essential for the nurse to document this finding to ensure ongoing monitoring of the fistula's status. Choices A, B, and D are incorrect. Choice A is incorrect because there is no indication to loosen the dressing. Choice B is incorrect as a bounding pulse is not associated with the palpable buzzing sensation of a thrill. Choice D is incorrect as applying pressure over the site is not necessary for this situation.

3. Which of the following is an appropriate intervention for a patient experiencing a hypertensive crisis?

• A. Placing the patient in a supine position
• B. Administering a beta-blocker intravenously
• C. Encouraging the patient to drink fluids
• D. Applying a cold compress to the forehead

Correct answer: B

Rationale: Administering a beta-blocker intravenously is the correct intervention for a patient experiencing a hypertensive crisis. Beta-blockers help quickly reduce blood pressure and prevent complications such as stroke or heart attack. Placing the patient in a supine position can worsen the condition by reducing venous return and increasing the workload of the heart. Encouraging the patient to drink fluids is not recommended as it can exacerbate hypertension by increasing fluid volume. Applying a cold compress to the forehead does not address the underlying cause of the hypertensive crisis and is unlikely to provide significant benefit.

4. While assessing an older male client who takes psychotropic medications, the nurse observes uncontrollable hand movements and excessive blinking. Which information in the client's medical record should the nurse review?

• A. Prescription for lorazepam
• B. History of Parkinson's disease
• C. Screening for tardive dyskinesia
• D. Recent urine drug screen report

Correct answer: C

Rationale: The symptoms of uncontrollable hand movements and excessive blinking are indicative of tardive dyskinesia, a possible side effect of long-term use of psychotropic medications. Reviewing the screening for tardive dyskinesia is crucial to assess if these symptoms are related to the medication. Option A, the prescription for lorazepam, is less relevant as the focus should be on potential side effects rather than the specific medication. Option B, history of Parkinson's disease, is not directly related to the observed symptoms, which are more likely linked to medication side effects. Option D, recent urine drug screen report, is not as pertinent in this context compared to reviewing the screening for tardive dyskinesia.

5. The practical nurse is caring for a client who had a total laryngectomy, left radical neck dissection, and tracheostomy. The client is receiving nasogastric tube feedings via an enteral pump. Today the rate of feeding is increased from 50 ml/hr to 75 ml/hr. What parameter should the PN use to evaluate the client's tolerance to the rate of the feeding?

• A. Daily weight
• B. Gastric residual volumes
• C. Bowel sounds
• D. Urinary and stool output

Correct answer: B

Rationale: Monitoring gastric residual volumes helps to assess how well the client is tolerating the increased feeding rate. High residuals may indicate delayed gastric emptying, which could lead to complications like aspiration. This helps in adjusting the feeding plan as necessary. Daily weight (Choice A) is not the most appropriate parameter to evaluate tolerance to feeding rate changes. Bowel sounds (Choice C) and urinary/stool output (Choice D) are important assessments but do not directly indicate tolerance to enteral feeding rate changes.

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