Nursing Elites

1. 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.

2. Following delivery of a newborn, the 21-year-old mother is experiencing mild vaginal bleeding. You note that her heart rate has increased from 90 to 120 beats/min and she is diaphoretic. Management should include

• A. Oxygen, uterine massage, and transport
• B. Oxygen, placement on the left side, and transport
• C. Oxygen, treatment for shock, and uterine massage during transport
• D. Oxygen, internal vaginal pads, and treatment for shock during transport

Correct answer: C

Rationale: In this scenario, the 21-year-old mother is showing signs of hemorrhagic shock with increased heart rate, diaphoresis, and vaginal bleeding. The appropriate management includes providing oxygen to support tissue perfusion, treating for shock to restore adequate circulation, and performing uterine massage to help control bleeding during transport. Options A, B, and D do not address the comprehensive management needed for postpartum hemorrhage in this situation.

3. The nurse is assessing a 9-year-old girl with a history of tuberculosis at age 6 years. She has been losing weight and has no appetite. The nurse suspects Addison disease based on which assessment findings?

• A. Arrested height and increased weight
• B. Thin, fragile skin and multiple bruises
• C. Hyperpigmentation and hypotension
• D. Blurred vision and enuresis

Correct answer: C

Rationale: In a child with suspected Addison disease, the presence of hyperpigmentation (bronzing of the skin) and hypotension are key clinical findings. Hyperpigmentation is due to increased ACTH stimulation, resulting in melanocyte stimulation. Hypotension occurs due to decreased aldosterone production and subsequent sodium loss. Choices A, B, and D are incorrect. Arrested height and increased weight are not typical of Addison disease; thin, fragile skin and multiple bruises are more indicative of conditions like Cushing's syndrome; blurred vision and enuresis are not typically associated with Addison disease.

4. A newborn is diagnosed with metatarsus adductus. The parents ask the nurse how this occurred. Which response by the nurse would be most appropriate?

• A. This condition is due to a genetic defect in the bones.
• B. It's most likely from how the baby was positioned in utero.
• C. They really don't know what causes this condition.
• D. There is probably an underlying deformity of the baby's hip.

Correct answer: B

Rationale: Metatarsus adductus is a condition characterized by the inward turning of the front part of the foot. It is often caused by the baby's position in the womb, leading to the foot adopting this position. Choice A is incorrect because metatarsus adductus is primarily related to positioning in utero rather than a genetic defect. Choice C is incorrect as there is an understanding of the common cause of this condition. Choice D is incorrect because metatarsus adductus specifically refers to a foot deformity, not a hip deformity.

5. A child with a diagnosis of leukemia is admitted to the hospital with a fever. What is the priority nursing intervention?

• A. Administering antibiotics
• B. Administering antipyretics
• C. Providing nutritional support
• D. Monitoring for signs of infection

Correct answer: D

Rationale: The priority nursing intervention for a child with leukemia admitted to the hospital with a fever is to monitor for signs of infection. Children with leukemia are immunocompromised, making them more susceptible to infections. Monitoring for signs of infection helps in early detection and timely intervention, which is crucial in preventing complications. Administering antibiotics (choice A) may be necessary if an infection is suspected or confirmed, but the priority is to assess for signs of infection first. Administering antipyretics (choice B) may help reduce fever, but it does not address the underlying cause, which could be an infection. Providing nutritional support (choice C) is important for overall health but is not the priority when a child with leukemia presents with a fever, as infection needs to be ruled out or managed first.

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