Nursing Elites

1. A nurse is assessing a school-age child with a urinary tract infection. What symptom should the nurse expect?

• A. Periorbital edema.
• B. Decreased frequency of urination.
• C. Enuresis.
• D. Diarrhea.

Correct answer: C

Rationale: The correct answer is C: Enuresis. Enuresis, which refers to involuntary urination, is a common symptom of urinary tract infections in children. Periorbital edema (choice A) is more commonly associated with conditions like nephrotic syndrome. Decreased frequency of urination (choice B) is not typically seen in urinary tract infections, as these infections often present with increased frequency. Diarrhea (choice D) is not a typical symptom of a urinary tract infection.

2. A nurse is planning care for a client who has a closed head injury and has an intraventricular catheter. Which of the following interventions should the nurse include to reduce the risk for infection?

• A. Keep the head of the bed elevated to 30 degrees.
• B. Administer IV antibiotics prophylactically.
• C. Change the catheter insertion site every 24 hours.
• D. Monitor the insertion site for redness.

Correct answer: D

Rationale: The correct answer is to monitor the insertion site for redness. This intervention helps detect signs of infection early in clients with intraventricular catheters. Keeping the head of the bed elevated to 30 degrees is important for managing intracranial pressure but does not directly reduce the risk of infection. Administering IV antibiotics prophylactically is not recommended as a routine practice due to the risk of antibiotic resistance and should only be done based on culture results. Changing the catheter insertion site every 24 hours is unnecessary and increases the risk of introducing new pathogens.

3. A nurse is assessing a client who has diabetes mellitus and is experiencing hyperglycemia. Which of the following findings should the nurse expect?

• A. Polyuria
• B. Hypoglycemia
• C. Diaphoresis
• D. Tachycardia

Correct answer: A

Rationale: Polyuria is the excessive production of urine and is a common finding in clients with hyperglycemia due to increased glucose levels. High blood sugar levels lead to the body trying to eliminate the excess glucose through urine, resulting in increased urination. Hypoglycemia (choice B) is low blood sugar and is not typically associated with hyperglycemia. Diaphoresis (choice C) is excessive sweating and is not a direct symptom of hyperglycemia. Tachycardia (choice D) is increased heart rate and is not a primary finding in hyperglycemia.

4. A client is receiving discharge teaching about a new prescription for ferrous sulfate. Which of the following statements by the client indicates an understanding of the teaching?

• A. I should take this medication with milk.
• B. I should expect my stools to turn black.
• C. I should avoid eating oranges while taking this medication.
• D. I will take this medication on an empty stomach.

Correct answer: B

Rationale: The correct answer is B. When taking ferrous sulfate, clients should expect their stools to turn black, which is a normal side effect due to the iron content. Choice A is incorrect because ferrous sulfate should not be taken with milk as it can decrease its absorption. Choice C is incorrect because vitamin C-rich foods like oranges can actually enhance the absorption of iron. Choice D is incorrect because ferrous sulfate is usually recommended to be taken on an empty stomach for better absorption.

5. A nurse is caring for a client who is in labor and is receiving electronic fetal monitoring. The nurse notes early decelerations. Which of the following should the nurse expect?

• A. Fetal hypoxia
• B. Head compression
• C. Placenta previa
• D. Umbilical cord prolapse

Correct answer: B

Rationale: In the scenario of early decelerations noted during labor with electronic fetal monitoring, the nurse should expect head compression. Early decelerations are a normal response to fetal head compression during contractions and are not indicative of fetal distress. Choice A, fetal hypoxia, is incorrect as early decelerations are not associated with fetal oxygen deprivation. Choices C and D, placenta previa and umbilical cord prolapse, are unrelated to the scenario described and do not cause early decelerations.

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