Nursing Elites

1. 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.

2. Which medication is most likely to cause serious respiratory depression as a potential adverse reaction?

• A. Morphine
• B. Pentazocine
• C. Hydrocodone
• D. Nalmefene

Correct answer: A

Rationale: Morphine, as a strong opioid agonist, has the highest likelihood of causing serious respiratory depression due to its potent effects on the central nervous system. While Pentazocine and Hydrocodone can also cause respiratory depression, they are less likely to do so compared to morphine. Nalmefene, an opioid antagonist, is used to reverse respiratory depression caused by opioids rather than causing it.

3. The healthcare professional is completing the intake and output record for a child admitted for fluid volume deficit. The child has had the following intake and output during the shift: 4 oz of Pedialyte, One-half of an 8-oz cup of clear orange Jell-O, Two graham crackers, 200 mL of D5 1/2 sodium chloride IV. Output: 345 mL of urine, 50 mL of loose stool. How many milliliters should the healthcare professional document as the client's total intake? Give the numerical answer only. Do not include any units of measurement.

• A. 440
• B. 400
• C. 410
• D. 450

Correct answer: A

Rationale: The total intake is 440 mL (4 oz of Pedialyte = 120 mL, half of an 8 oz cup of Jell-O = 120 mL, and 200 mL of IV fluids). The graham crackers are not counted as intake. Therefore, the correct answer is 440. Choice B (400) is incorrect because it does not account for the intake of Jell-O. Choice C (410) is incorrect as it does not include the Pedialyte intake. Choice D (450) is incorrect because it overestimates the total intake by including the graham crackers.

4. Which assessment finding, after the dialysate is drained during peritoneal dialysis for a child experiencing acute renal failure, would warrant further action by the nurse?

• A. The dialysate is clear upon return.
• B. The volume of drained dialysate is less than the volume infused.
• C. The child is restless and eager to play.
• D. The child's vital signs remain consistent with those noted during infusion.

Correct answer: B

Rationale: A lower volume of drained dialysate compared to the volume infused suggests a possible obstruction or malfunction in the dialysis process. This finding could compromise the effectiveness of the treatment and needs prompt assessment and intervention by the nurse to ensure the child's safety and well-being. Choices A, C, and D are not indicative of complications during peritoneal dialysis. The clarity of the dialysate, the child's behavior, and the consistency of vital signs are not alarming findings that would require immediate action by the nurse.

5. The patient taking spironolactone (Aldactone) makes a statement indicating effective teaching. Which statement shows understanding of the teaching?

• A. I will use salt substitutes to lower my sodium intake
• B. I will increase my intake of foods that are high in potassium
• C. I will call my doctor if I begin having menstrual irregularities
• D. I will take this medication at bedtime each evening

Correct answer: C

Rationale: The correct answer is C because spironolactone is a potassium-sparing diuretic that can cause endocrine effects like menstrual irregularities. Therefore, the patient recognizing the need to report such changes indicates effective teaching. Choices A and B are incorrect as salt substitutes and high-potassium foods should be avoided with spironolactone. Choice D is also incorrect because diuretics, including spironolactone, are ideally taken in the morning to prevent disturbances in sleep due to nocturia.

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