Nursing Elites

1. A nasogastric tube for suction is ordered for a neonate diagnosed with a diaphragmatic hernia. Which complication related to gastric drainage is the priority when planning care for this neonate?

• A. Weight loss
• B. Metabolic alkalosis
• C. Dehydration
• D. Hyperbilirubinemia

Correct answer: B

Rationale: Metabolic alkalosis is the priority complication to consider when a neonate with a diaphragmatic hernia is placed on gastric suction. Prolonged gastric drainage can lead to the loss of stomach acids, resulting in metabolic alkalosis, which can have serious consequences for the neonate's health.

2. A healthcare provider is assessing the pain level of a three-year-old toddler. Which of the following pain assessment scales should the healthcare provider use?

• A. FACES Pain rating scale
• B. Numeric pain rating scale
• C. CRIES pain assessment scale
• D. Non-communicating children's pain checklist

Correct answer: A

Rationale: The healthcare provider should use the FACES pain rating scale for pediatric clients who are 3 years old and older. This scale allows the toddler to point to the face that depicts the current level of pain, making it a suitable choice for non-verbal or young children who may have difficulty expressing their pain verbally.

3. Which clean-catch urinalysis finding should raise the most concern for a child admitted to an urgent care center to rule out a urinary tract infection?

• A. 2+ white blood cells
• B. 1+ red blood cells
• C. Urine appearance: cloudy
• D. Specific gravity: 1.009

Correct answer: D

Rationale: A specific gravity of 1.009 is low, indicating diluted urine, which can be concerning in the context of a urinary tract infection. Diluted urine may suggest inadequate concentration due to increased fluid intake or impaired kidney function, which are important considerations in the assessment of a possible UTI.

4. Which assessment finding would necessitate action by the nurse for a 10-month-old child who is 4 hours postoperative for the placement of a urethral stent?

• A. Bloody urine
• B. One void since returning from surgery
• C. Bladder spasms responding to pharmacologic intervention
• D. Double diapering from the previous shift

Correct answer: B

Rationale: In a postoperative scenario after the placement of a urethral stent, monitoring the child's voiding frequency is crucial. Having only one void since returning from surgery could indicate potential issues like urinary retention, which necessitates prompt nursing intervention to prevent complications.

5. During an assessment, an infant is suspected to have intussusception. Which of the following findings should the nurse expect?

• A. Currant jelly stools
• B. Projectile vomiting
• C. Scaphoid abdomen
• D. Frequent stools

Correct answer: A

Rationale: Intussusception is a condition where one segment of the intestine telescopes into another, causing obstruction. The classic presentation includes currant jelly stools, which are a mixture of blood and mucus due to the sloughing of the intestinal mucosa. This finding is a result of the compromised blood supply to the affected area and is a key characteristic associated with intussusception.

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