Nursing Elites

1. A nurse is caring for a 2-day-old infant who has a bilirubin level of 19 mg/dl. The physician has ordered phototherapy. Which of the following actions indicates correct preparation of the infant for this procedure?

• A. Undress the baby down to a diaper and hat
• B. Place the baby in his mother's arms before turning on the light
• C. Position the phototherapy light approximately 3 inches above the baby's skin
• D. Secure eye protection for the infant without occluding the nose

Correct answer: D

Rationale: Phototherapy is used to treat high levels of bilirubin among infants, typically evidenced as jaundice. The nurse must position the infant carefully during this procedure to maximize the benefits of the light therapy while protecting the baby. Placing protective eyewear over the baby's eyes without covering the nose is crucial to shield the eyes from the ultraviolet light. Undressing the baby down to a diaper and hat (Choice A) is a standard practice to maximize skin exposure to the phototherapy light. Placing the baby in his mother's arms before turning on the light (Choice B) is not necessary for the preparation of the infant for phototherapy. Positioning the phototherapy light approximately 3 inches above the baby's skin (Choice C) is incorrect as the distance should be as recommended by the healthcare provider based on the manufacturer's instructions.

2. When analyzing the results of the urinalysis collected preoperatively from a child with epispadias scheduled for surgical repair, which finding should the nurse most likely expect to note?

• A. Hematuria
• B. Proteinuria
• C. Bacteriuria
• D. Glucosuria

Correct answer: C

Rationale: Epispadias is a congenital defect characterized by the abnormal placement of the urethral orifice of the penis, often on the dorsum. This anatomical anomaly predisposes individuals to bacterial entry into the urinary tract, leading to bacteriuria. Hematuria, proteinuria, and glucosuria are not typically associated with epispadias. Hematuria refers to the presence of blood in the urine, proteinuria indicates protein in the urine, and glucosuria is the presence of glucose in the urine, none of which are commonly seen in epispadias.

3. The nurse is preparing to administer an enteral feeding to a client via a nasogastric feeding tube. The most important action of the nurse is:

• A. Verify correct placement of the tube
• B. Check that the feeding solution matches the dietary order
• C. Aspirate gastric contents to determine the amount of the last feeding remaining in the stomach
• D. Ensure that the feeding solution is at room temperature

Correct answer: A

Rationale: The most crucial action for the nurse when preparing to administer enteral feeding via a nasogastric tube is to verify the correct placement of the tube. Proper placement of the tube is vital to prevent complications such as aspiration into the lungs. The definitive methods to confirm the position of the nasogastric tube include visualization through an x-ray or aspirating stomach contents and checking their pH (usually pH 1 to 5). Aspirated stomach content can also be tested for bilirubin to confirm placement in the stomach. Choice B, checking that the feeding solution matches the dietary order, is important for ensuring the correct nutrition is provided but is not as critical as verifying tube placement to prevent potential harm. Choice C, aspirating gastric contents to determine the amount of the last feeding remaining in the stomach, is a common nursing practice but is not the most crucial action when compared to ensuring correct tube placement. Choice D, ensuring that the feeding solution is at room temperature, is relevant for patient comfort and preventing thermal injury but is not as essential as confirming correct tube placement to prevent serious complications.

4. When assessing a child admitted to the hospital with pyloric stenosis, which symptom would the nurse likely find when asking the parent about the child's symptoms?

• A. Watery diarrhea
• B. Projectile vomiting
• C. Increased urine output
• D. Vomiting large amounts of bile

Correct answer: B

Rationale: In pyloric stenosis, hypertrophy of the circular muscles of the pylorus causes narrowing of the pyloric canal between the stomach and the duodenum. The hallmark symptom of pyloric stenosis is projectile vomiting, which is the forceful expulsion of stomach contents. Other common symptoms include irritability, hunger and crying, constipation, and signs of dehydration. Watery diarrhea (Choice A) is not a typical symptom of pyloric stenosis. Increased urine output (Choice C) is not directly associated with this condition. Vomiting large amounts of bile (Choice D) is not a characteristic symptom of pyloric stenosis; instead, the vomitus in pyloric stenosis is non-bilious.

5. The nurse is caring for a client with a serum potassium level of 3.5 mEq/L. The client is placed on a cardiac monitor and receives 40 mEq potassium chloride in 1000 ml of 5% dextrose in water IV. Which of the following EKG patterns indicates to the nurse that the infusions should be discontinued?

• A. Narrowed QRS complex
• B. Shortened "PR"? interval
• C. Tall peaked "T"? waves
• D. Prominent "U"? waves

Correct answer: C

Rationale: A tall peaked T wave is a characteristic EKG pattern associated with hyperkalemia. Hyperkalemia refers to high levels of potassium in the blood, which can lead to cardiac arrhythmias and other serious complications. Tall peaked T waves are a red flag for potential cardiac issues and can indicate the need to discontinue potassium infusions. The other choices, such as narrowed QRS complex, shortened "PR"? interval, and prominent "U"? waves, are not typically associated with hyperkalemia. Therefore, recognizing tall peaked T waves is crucial for the nurse to take prompt action in managing the client's condition.

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