Nursing Elites

1. A home care nurse is visiting a family for the first time. The 4-week-old infant had surgery for exstrophy of the bladder and creation of an ileal conduit soon after birth. When the nurse arrives, the mother appears tired, and the baby is crying. After an introduction, which is the most appropriate statement by the nurse?

• A. “Tell me about your daily routine.”
• B. “You look tired. Is everything alright?”
• C. “When was the last time the baby had a bottle?”
• D. “Oh, it looks like you two are having a bad day.”

Correct answer: A

Rationale: Asking about the daily routine is the most appropriate statement by the nurse in this scenario. It allows the nurse to gather important information about the family's schedule, feeding patterns, and overall care routine for the infant. This open-ended question helps the nurse assess the family's situation comprehensively and identify any areas where support may be needed. Choices B, C, and D are less appropriate as they do not focus on gathering relevant information about the family's routine and needs but rather make assumptions or ask about specific isolated events.

2. When administering IV fluids to a dehydrated infant, what intervention is most important at this time?

• A. Continuing the prescribed flow rate
• B. Monitoring the intravenous drop rate
• C. Calculating the total necessary intake
• D. Maintaining the fluid at body temperature

Correct answer: B

Rationale: Monitoring the intravenous drop rate is the most crucial intervention when administering IV fluids to a dehydrated infant. This ensures that the correct amount of fluids is being delivered to the infant at the appropriate rate. While continuing the prescribed flow rate (Choice A) may be important, it does not allow for real-time adjustments that may be necessary during the infusion. Calculating the total necessary intake (Choice C) should have been determined before initiating IV therapy. Maintaining the fluid at body temperature (Choice D) is important for patient comfort but is not as critical as ensuring the proper administration of fluids.

3. A 7-year-old child with a history of seizures is being discharged from the hospital. What should the nurse include in the discharge teaching for the parents?

• A. Administer antiepileptic medication as prescribed, not just when a seizure occurs
• B. Ensure the child gets adequate sleep
• C. Restrict the child's activities to prevent seizures
• D. Teach seizure first aid to family members

Correct answer: D

Rationale: The correct answer is to teach seizure first aid to family members. This is crucial because family members need to know how to appropriately respond during a seizure to ensure the child's safety. Choice A has been corrected to emphasize that antiepileptic medication should be administered as prescribed, not just when a seizure occurs, to effectively manage the condition. Choice B, while important for overall health, is not directly related to seizure management. Choice C is not recommended as restricting activities may not prevent seizures and may hinder the child's quality of life.

4. A child with a diagnosis of gastroesophageal reflux disease (GERD) is being discharged. What dietary instructions should the nurse provide?

• A. Avoid spicy foods
• B. Avoid gluten
• C. Avoid high-fat foods
• D. Avoid dairy products

Correct answer: C

Rationale: The correct dietary instruction for a child with GERD is to avoid high-fat foods. High-fat foods can relax the lower esophageal sphincter, leading to increased reflux. While avoiding gluten may be necessary for individuals with gluten sensitivity or celiac disease, it is not a standard recommendation for GERD. Avoiding spicy foods and dairy products may help some individuals with GERD, but the most crucial dietary advice is to avoid high-fat foods.

5. The nurse is developing a plan of care for a 7-year-old boy with diabetes insipidus. What is the priority nursing diagnosis?

• A. Deficient fluid volume related to dehydration
• B. Excess fluid volume related to edema
• C. Deficient knowledge related to fluid intake regimen
• D. Imbalanced nutrition related to excess weight

Correct answer: A

Rationale: The priority nursing diagnosis for a 7-year-old boy with diabetes insipidus is deficient fluid volume related to dehydration. Diabetes insipidus causes excessive thirst and urination, leading to fluid imbalance and potential dehydration. Choice B, excess fluid volume related to edema, is not a priority as diabetes insipidus is characterized by fluid loss, not retention. Choice C, deficient knowledge related to fluid intake regimen, may be important but is not the priority when the child is at risk of dehydration. Choice D, imbalanced nutrition related to excess weight, is not directly associated with the primary concern of fluid volume imbalance in diabetes insipidus.

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