Nursing Elites

1. A nurse is caring for a 2-year-old child after corrective surgery for Tetralogy of Fallot. The mother reports that the child has suddenly begun seizing. The nurse recognizes this problem is probably due to

• A. A cerebral vascular accident
• B. Postoperative meningitis
• C. Medication reaction
• D. Metabolic alkalosis

Correct answer: A

Rationale: The correct answer is a cerebral vascular accident. Polycythemia occurs as a physiological reaction to chronic hypoxemia, which commonly occurs in clients with Tetralogy of Fallot. Polycythemia and the resultant increased viscosity of the blood increase the risk of thromboembolic events, including cerebrovascular accidents. Signs and symptoms of a cerebral vascular accident include sudden paralysis, altered speech, extreme irritability or fatigue, and seizures. Postoperative meningitis (choice B) is less likely in this scenario as the sudden onset of seizing is more indicative of a vascular event rather than an infection. Medication reaction (choice C) is not the most probable cause given the history provided. Metabolic alkalosis (choice D) is not associated with sudden seizing in this context.

2. The healthcare provider calculates the IV flow rate for a patient receiving lactated Ringer's solution. The patient needs to receive 2000mL of Lactated Ringer's over 36 hours. The IV infusion set has a drop factor of 15 drops per milliliter. How many drops per minute should the healthcare provider set the IV to deliver?

• A. 8
• B. 10
• C. 14
• D. 18

Correct answer: C

Rationale: To determine the drops per minute, we use the formula Drops Per Minute = (Milliliters x Drop Factor) / Time in Minutes. In this case, Drops Per Minute = (2000mL x 15 drops/mL) / (36 hours x 60 minutes/hour) = 30000 / 2160 = 13.89 (approximately 14). Therefore, the correct answer is 14 drops per minute. Choice A (8), Choice B (10), and Choice D (18) are incorrect as they do not correctly calculate the drops per minute based on the given information.

3. A 3-year-old had a hip spica cast applied 2 hours ago. In order to facilitate drying, the nurse should

• A. Expose the cast to air and turn the child frequently
• B. Use a heat lamp to reduce the drying time
• C. Handle the cast with the abductor bar
• D. Turn the child as little as possible

Correct answer: A

Rationale: After applying a hip spica cast, it is important to facilitate drying by exposing the cast to air and turning the child frequently. This helps promote even drying and prevents complications such as skin breakdown. Using a heat lamp can cause burns and is not recommended. Handling the cast with the abductor bar does not aid in drying the cast. Turning the child as little as possible is incorrect as regular turning is crucial to prevent complications.

4. While receiving normal saline infusions to treat a GI bleed, the nurse notes that the patient's lower legs have become edematous and auscultates crackles in the lungs. What should the nurse do first?

• A. Stop the saline infusion immediately
• B. Notify the physician
• C. Elevate the patient's legs
• D. Continue the infusion, as these findings are normal

Correct answer: A

Rationale: The correct answer is to stop the saline infusion immediately. The patient is showing signs of fluid volume overload due to rapid fluid replacement, indicated by lower leg edema and lung crackles. Continuing the infusion could worsen the overload and potentially lead to complications. Notifying the physician is important but should come after stopping the infusion to address the immediate issue. Elevating the patient's legs may help with edema but is not the priority in this situation. Continuing the infusion when the patient is already showing signs of fluid overload is contraindicated and can be harmful.

5. A patient with a history of diabetes mellitus is on the second postoperative day following cholecystectomy. She has complained of nausea and isn't able to eat solid foods. The nurse enters the room to find the patient confused and shaky. Which of the following is the most likely explanation for the patient's symptoms?

• A. Anesthesia reaction
• B. Hyperglycemia
• C. Hypoglycemia
• D. Diabetic ketoacidosis

Correct answer: C

Rationale: In a postoperative diabetic patient who is unable to eat solid foods, the likely cause of symptoms such as confusion and shakiness is hypoglycemia. Confusion and shakiness are common manifestations of hypoglycemia. Insufficient glucose supply to the brain (neuroglycopenia) can lead to confusion, difficulty with concentration, irritability, hallucinations, focal impairments like hemiplegia, and, in severe cases, coma and death. Anesthesia reaction (Choice A) is less likely in this scenario as the patient is already on the second postoperative day. Hyperglycemia (Choice B) is unlikely given the patient's symptoms and history of not eating. Diabetic ketoacidosis (Choice D) typically presents with hyperglycemia, ketosis, and metabolic acidosis, which are not consistent with the patient's current symptoms of confusion and shakiness.

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