Nursing Elites

1. A nurse in an emergency department is caring for a school-age child who is experiencing an anaphylactic reaction. Which of the following is the priority action by the nurse?

• A. Elevate the head of the child's bed
• B. Insert a large-bore IV catheter for the child
• C. Determine the allergen that caused the child's reaction
• D. Administer IM epinephrine to the child

Correct answer: D

Rationale: In the management of anaphylaxis, the priority action for the nurse is to administer IM epinephrine to the child. Epinephrine is the first-line treatment for anaphylaxis as it helps reverse the severe manifestations of the reaction by constricting blood vessels, relaxing airway muscles, and decreasing hives and swelling. Elevating the head of the child's bed may be beneficial for respiratory distress but is not the priority over administering epinephrine. Inserting a large-bore IV catheter may be necessary for fluid resuscitation but is not the initial priority. Identifying the allergen is important for prevention and future management but is not the immediate action needed in the acute phase of an anaphylactic reaction.

2. A patient is prescribed fluconazole (Diflucan) for a vaginal yeast infection. The nurse should be concerned if the patient is also taking which medication?

• A. Losartan (Cozaar)
• B. Simvastatin (Zocor)
• C. Lisinopril (Zestril)
• D. Hydrochlorothiazide (HCTZ)

Correct answer: B

Rationale: When fluconazole is taken with statins like simvastatin, it can increase the levels of the statin in the blood, potentially leading to adverse effects such as muscle pain and weakness. Therefore, the nurse should be concerned if the patient is taking simvastatin along with fluconazole.

3. When conducting an initial feeding evaluation, the therapist asks the caregiver to bring the utensils, food, and high chair that they typically use. Which statement best reflects the therapist's reasoning for this?

• A. Using the child's actual materials will give the therapist an accurate picture
• B. The therapist wants to be sensitive to the child's culture
• C. The center has limited funds for food and materials
• D. The therapist would like to know if the caregiver can follow directions

Correct answer: A

Rationale: By having the caregiver bring the child's familiar utensils, food, and high chair, the therapist can observe the child's typical eating behaviors and challenges accurately. This provides valuable insights that help in tailoring appropriate interventions to address feeding issues effectively.

4. A healthcare professional is assessing a child who has a rotavirus infection. Which of the following is an expected manifestation?

• A. Constipation
• B. Vomiting
• C. Jaundice
• D. Abdominal pain

Correct answer: B

Rationale: Vomiting is a common manifestation of rotavirus infection in children. Rotavirus typically presents with symptoms such as watery diarrhea, vomiting, fever, and abdominal pain. Constipation, jaundice, and abdominal pain are less commonly associated with rotavirus infection in children.

5. A nurse is planning care for a 2-month-old infant who is postoperative following surgical repair of a cleft lip. Which of the following actions should the nurse take?

• A. Position the infant on his abdomen
• B. Cleanse the incision site with hydrogen peroxide
• C. Offer the infant a pacifier
• D. Keep the infant's elbow restrained

Correct answer: D

Rationale: The nurse should keep the infant�s elbow restrained to prevent injury to the surgical site.

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