Nursing Elites

1. A nurse is caring for an infant with intractable vomiting. For what complication is it most important for the nurse to assess?

• A. Acidosis
• B. Alkalosis
• C. Hyperkalemia
• D. Hypernatremia

Correct answer: B

Rationale: When an infant experiences intractable vomiting, it can lead to the loss of stomach acids, resulting in metabolic alkalosis. Alkalosis is characterized by elevated blood pH and can lead to serious complications. Assessing for alkalosis is essential in this scenario to monitor and manage the infant's condition. Choices A, C, and D are incorrect because in this context, the primary concern is the metabolic imbalance caused by excessive vomiting, leading to alkalosis rather than acidosis, hyperkalemia, or hypernatremia.

2. A child with a cardiac malformation associated with left-to-right shunting is being cared for by a nurse. What does the nurse consider to be the major characteristic of this type of congenital disorder?

• A. Elevated hematocrit
• B. Severe growth retardation
• C. Clubbing of the fingers and toes
• D. Increased blood flow to the lungs

Correct answer: D

Rationale: The major characteristic of a cardiac malformation associated with left-to-right shunting is increased blood flow to the lungs. This increased flow can lead to pulmonary hypertension and heart failure if left untreated. Elevated hematocrit (Choice A) is not a typical characteristic of this condition. Severe growth retardation (Choice B) is not directly associated with left-to-right shunting. Clubbing of the fingers and toes (Choice C) is more commonly seen in conditions involving chronic hypoxia.

3. When a parent tells a nurse at the clinic, 'Each morning I offer my 24-month-old child juice, and all I hear is ‘No.’ What should I do because I know my child needs fluid?' What strategy should the nurse suggest?

• A. Offer the child a choice of two juices.
• B. Distract the child with a favorite food.
• C. Offer the child the glass in a firm manner.
• D. Allow the child to see the parent getting angry.

Correct answer: A

Rationale: The nurse should suggest offering the child a choice of two juices. Giving the child a choice between two options empowers them to make a decision, fostering a sense of control, and increasing the likelihood of cooperation. This approach respects the child's autonomy while addressing the parent's concern about the child's fluid intake. Choices B, C, and D are incorrect because distracting the child, offering the glass in a firm manner, or displaying anger are not effective strategies for encouraging a 24-month-old child to drink juice.

4. A 4-year-old child is brought to the emergency department with a suspected fracture. What is the priority nursing action?

• A. Immobilize the affected limb
• B. Apply ice to the affected area
• C. Elevate the affected limb
• D. Check the child's neurovascular status

Correct answer: A

Rationale: The priority nursing action when a child with a suspected fracture is brought to the emergency department is to immobilize the affected limb. Immobilization helps prevent further injury until a fracture is confirmed or ruled out. Applying ice or elevating the limb can wait until after immobilization has been achieved. Checking the child's neurovascular status is important but is not the priority action in this situation.

5. A nurse is providing care to a child diagnosed with sickle cell anemia. What is the priority nursing intervention?

• A. Administering pain medication
• B. Ensuring adequate hydration
• C. Providing nutritional support
• D. Monitoring vital signs

Correct answer: A

Rationale: In sickle cell anemia, pain management is a priority due to vaso-occlusive crises that cause severe pain. Administering pain medication helps alleviate discomfort and improve the child's quality of life. Ensuring adequate hydration, although important, is secondary to addressing the immediate pain issue. Providing nutritional support is beneficial for overall health but does not address the acute pain experienced. Monitoring vital signs is essential but not the immediate priority when managing pain in sickle cell anemia.

Similar Questions