Nursing Elites

1. A child with glomerulonephritis is asking for strawberries. What should the nurse do?

• A. Allow the child to eat strawberries.
• B. Restrict the child's diet.
• C. Give the child a low-protein diet.
• D. Increase the child's fluid intake.

Correct answer: B

Rationale: In glomerulonephritis, it is crucial to restrict the child's diet, particularly avoiding foods high in potassium like strawberries. Potassium restriction is essential because impaired kidney function in glomerulonephritis can lead to potassium retention, potentially causing hyperkalemia. Therefore, the nurse should restrict the child's diet to manage their condition effectively.

2. The nurse is caring for a one-year-old child following surgical correction of hypospadias. Which nursing action has the highest priority?

• A. Monitor urinary output
• B. Auscultate bowel sounds
• C. Observe appearance of stool
• D. Record percent of diet consumed

Correct answer: A

Rationale: In caring for a one-year-old child post hypospadias surgery, the highest priority action is to monitor urinary output. This is crucial to assess kidney function and ensure there are no complications following the surgical procedure. Auscultating bowel sounds, observing stool appearance, and recording diet consumption are important assessments too, but in this case, monitoring urinary output takes precedence due to the nature of the surgery and potential complications related to urinary function.

3. The client is admitted in active labor with a cervix that is 3 cm dilated, 50% effaced, and the presenting part at 0 station. An hour later, the client expresses the need to go to the bathroom. Which action should the nurse implement first?

• A. Palpate the client’s bladder.
• B. Check the pH of the vaginal fluid.
• C. Review the fetal heart rate pattern.
• D. Determine cervical dilation.

Correct answer: D

Rationale: The nurse should prioritize determining cervical dilation as it helps in assessing the progress of labor and ensures it is safe for the client to move. Changes in cervical dilation may indicate the advancement of labor, warranting appropriate interventions or restrictions on movement to prevent complications. While checking the client's bladder may be important to ensure it's not distended, determining cervical dilation takes precedence in this scenario. Checking the pH of the vaginal fluid is not relevant in this situation, and reviewing the fetal heart rate pattern, although important, is not the first action to take when the client expresses the need to go to the bathroom.

4. A 6-year-old with heart failure (HF) gained 2 pounds in the last 24 hours. Which intervention is more important for the nurse to implement?

• A. Graph the daily weight for the past week.
• B. Decrease IV flow rate.
• C. Assess bilateral lung sounds.
• D. Restrict intake of oral fluids.

Correct answer: C

Rationale: Assessing bilateral lung sounds is crucial in this scenario as it can provide essential information about potential fluid accumulation in the lungs, indicating worsening heart failure. This assessment can guide immediate interventions to prevent further deterioration in the patient's condition.

5. A woman who gave birth 48 hours ago is bottle-feeding her infant. During assessment, the nurse determines that both breasts are swollen, warm, and tender upon palpation. What action should the LPN/LVN take?

• A. Apply cold compresses to both breasts for comfort.
• B. Instruct the client to run warm water on her breasts.
• C. Wear a loose-fitting bra to prevent nipple irritation.
• D. Express small amounts of milk to relieve pressure.

Correct answer: A

Rationale: After childbirth, engorgement of the breasts can occur, leading to swelling and discomfort. Applying cold compresses helps reduce swelling and provides comfort for engorged breasts. This action can also help with pain relief and promote milk flow regulation. Instructing the client to run warm water on her breasts (Choice B) is incorrect as warm water can increase blood flow and exacerbate swelling. Wearing a loose-fitting bra (Choice C) may provide some comfort, but it does not address the swelling effectively. Expressing small amounts of milk (Choice D) may provide temporary relief but does not address the underlying issue of engorgement.

Similar Questions