Nursing Elites

1. A child with pertussis is receiving azithromycin (Zithromax Injection) IV. Which intervention is most important for the nurse to include in the child's plan of care?

• A. Obtain vital signs to monitor for fluid overload
• B. Change IV site dressing every 3 days and as needed
• C. Monitor for signs of facial swelling or urticaria
• D. Assess for abdominal pain and vomiting

Correct answer: C

Rationale: When administering azithromycin IV, monitoring for signs of an allergic reaction, such as facial swelling or urticaria, is crucial. This helps in early detection of potential adverse reactions and ensures prompt intervention to prevent complications associated with the medication. The other options are not directly related to the administration of azithromycin IV in this scenario. Monitoring for fluid overload would be more relevant for fluid administration, changing IV site dressing is important but not the priority in this case, and assessing for abdominal pain and vomiting may be important but not as critical as monitoring for signs of an allergic reaction.

2. What is the most important information for the PN to reinforce with the parents when caring for a child diagnosed with acute rheumatic fever?

• A. Complete the full course of prescribed antibiotics.
• B. Ensure the child gets plenty of physical exercise.
• C. Keep the child on a low-sodium diet.
• D. Administer prescribed pain medications as needed.

Correct answer: A

Rationale: Completing the full course of antibiotics is crucial in the management of acute rheumatic fever as it helps prevent recurrence and complications. Antibiotics are essential in eradicating the underlying infection that triggers the autoimmune response leading to rheumatic fever. Reinforcing the importance of completing the prescribed antibiotic regimen is vital to ensure the child's recovery and prevent further health issues. Choices B, C, and D are not as critical as completing the antibiotic treatment. While physical exercise, a low-sodium diet, and pain management are important aspects of overall health, they are not the primary focus when managing acute rheumatic fever.

3. A 15-year-old adolescent with anorexia nervosa is admitted to the hospital for severe weight loss. The nurse notes that the client has dry skin, brittle hair, and is severely underweight. What is the nurse’s priority intervention?

• A. Establish a therapeutic relationship with the client
• B. Monitor the client’s vital signs frequently
• C. Initiate a structured eating plan
• D. Provide education about healthy eating habits

Correct answer: C

Rationale: In this scenario, the priority intervention for the nurse is to initiate a structured eating plan. Anorexia nervosa is a serious eating disorder characterized by severe food restriction, which can lead to malnutrition and severe weight loss. By starting a structured eating plan, the nurse can ensure the client receives the necessary nutrition to begin the process of weight restoration and recovery. Monitoring vital signs is essential, but without addressing the nutrition deficiency, vital signs may not improve significantly. Establishing a therapeutic relationship is crucial for long-term care but may not address the immediate risk of malnutrition. Providing education about healthy eating habits is important but may not be effective initially due to the severity of the client's condition.

4. A child with Graves' disease who is taking propranolol (Inderal) is seen in the clinic. The nurse should monitor the child for which therapeutic response?

• A. Increased weight gain
• B. Decreased heart rate
• C. Reduced headaches
• D. Diminished fatigue

Correct answer: B

Rationale: The correct answer is B: 'Decreased heart rate.' Propranolol is a beta-blocker commonly used to manage symptoms of hyperthyroidism, including tachycardia. Monitoring for a decreased heart rate is important as it indicates the drug's therapeutic response in controlling the elevated heart rate associated with Graves' disease. Choices A, C, and D are incorrect because weight gain, reduced headaches, and diminished fatigue are not typical therapeutic responses to propranolol in the context of managing Graves' disease.

5. The caregiver is caring for a 3-year-old child with a diagnosis of gastroenteritis. The child has had several episodes of vomiting and diarrhea over the past 24 hours. What is the caregiver's priority assessment?

• A. Monitor the child's weight
• B. Assess the child's hydration status
• C. Evaluate the child's nutritional intake
• D. Check the child's temperature

Correct answer: B

Rationale: The correct answer is B: Assess the child's hydration status. In children with gastroenteritis, assessing hydration status is crucial as they are at risk of dehydration due to vomiting and diarrhea. Monitoring hydration helps prevent complications and guides appropriate interventions to maintain the child's fluid balance. Monitoring the child's weight (Choice A) is not the priority in this situation compared to assessing hydration status. Evaluating nutritional intake (Choice C) is important but not the priority when the child is at risk of dehydration. Checking the child's temperature (Choice D) is relevant but not the priority over assessing hydration status in a child with gastroenteritis.

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