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 healthcare professional is reviewing the clinical records of infants and children with cardiac disorders who developed heart failure. What did the professional determine is the last sign of heart failure?

• A. Tachypnea
• B. Tachycardia
• C. Peripheral edema
• D. Periorbital edema

Correct answer: C

Rationale: Peripheral edema is often considered the last sign of heart failure in infants and children. It indicates significant fluid retention and circulatory compromise. Tachypnea (increased respiratory rate) and tachycardia (increased heart rate) are early signs of heart failure due to inadequate cardiac output. Periorbital edema, while a sign of excess fluid, typically occurs earlier in the progression of heart failure compared to peripheral edema.

3. A child with a diagnosis of diabetes mellitus is being discharged from the hospital. What is important for the nurse to include in the discharge teaching?

• A. Monitor blood glucose levels daily
• B. Administer insulin based on blood glucose levels
• C. Recognize signs of hypoglycemia
• D. Follow a structured meal plan

Correct answer: D

Rationale: Following a structured meal plan is essential for managing diabetes mellitus. It helps regulate blood glucose levels and ensures proper nutrition. Monitoring blood glucose levels daily is important, not just once a day, to maintain control. Administering insulin based on blood glucose levels is crucial but should be done as per the healthcare provider's instructions, not only when blood glucose is high. Recognizing signs of hypoglycemia is important, but it is equally vital to prevent hypoglycemia by adhering to a consistent meal plan and insulin regimen.

4. The caregiver explains to the parent of a 2-year-old child that the toddler’s negativism is expected at this age. What need is this behavior meeting?

• A. Trust
• B. Attention
• C. Discipline
• D. Independence

Correct answer: D

Rationale: Negativism in toddlers is a common behavior at this age as they begin to assert their independence and show a desire to control their environment. Choice A, 'Trust,' does not align with the behavior of negativism, as it is more about the child's growing autonomy. Choice B, 'Attention,' while important for child development, is not the primary need being met by negativism in this context. Choice C, 'Discipline,' though important in guiding behavior, is not the underlying need being expressed through negativism. Therefore, the correct answer is D, 'Independence,' as toddlers exhibit negativism as a way to assert their independence and autonomy.

5. The nurse is providing care to a child with a long-leg hip spica cast. What is the priority nursing diagnosis?

• A. Risk for impaired skin integrity due to cast and location.
• B. Deficient knowledge related to cast care.
• C. Risk for delayed development related to immobility.
• D. Self-care deficit related to immobility.

Correct answer: A

Rationale: The correct answer is A: Risk for impaired skin integrity due to cast and location. When caring for a child with a long-leg hip spica cast, the priority nursing diagnosis is the risk for impaired skin integrity. This is because the child's limited mobility and the pressure from the cast can lead to skin breakdown and complications. Choice B is incorrect as while education is essential, it is not the priority when immediate physical risks are present. Choice C is incorrect because while immobility can impact development, the immediate concern is preventing complications from the cast. Choice D is incorrect as it focuses on self-care deficits rather than the physical risk of skin integrity issues.

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