Nursing Elites

1. When a patient is taking glucocorticoids and digoxin, which electrolyte should the nurse prioritize monitoring?

• A. Calcium
• B. Magnesium
• C. Sodium
• D. Potassium

Correct answer: D

Rationale: The nurse should primarily monitor potassium levels in a patient taking glucocorticoids and digoxin. Glucocorticoids can lead to potassium loss, potentially increasing the risk of digoxin toxicity. Additionally, glucocorticoids may worsen hypokalemia induced by diuretics like thiazides and loops. While calcium, magnesium, and sodium are important electrolytes to monitor in various clinical situations, they are not the priority in this specific scenario of a patient on glucocorticoids and digoxin.

2. The nurse is providing care for a pediatric client in the emergency department (ED) with a diagnosis of decreased level of consciousness (LOC) secondary to increased intracranial pressure (ICP). Which healthcare provider order should the nurse question?

• A. Passive range-of-motion exercises to promote hip flexion
• B. Oxygen at 2 L nasal cannula to maintain saturation above 95%
• C. Hourly vital signs and neurologic checks
• D. Elevate head of bed 30 degrees

Correct answer: A

Rationale: In a pediatric client with increased intracranial pressure (ICP) and decreased level of consciousness (LOC), passive range-of-motion exercises to promote hip flexion should be questioned as they can potentially increase intracranial pressure. This action may not be safe for the client's condition. The other options are appropriate interventions for managing a pediatric client with increased ICP and decreased LOC.

3. During a physical assessment of a hospitalized 5-year-old child, the healthcare provider notes that the foreskin has been retracted and is very tight on the shaft of the penis; they are unable to return it over the head of the penis. What action should the healthcare provider implement?

• A. Forcibly push the foreskin down over the head of the penis.
• B. Place a warm compress on the penis.
• C. Notify the healthcare provider in charge.
• D. Wait a few hours and try again.

Correct answer: C

Rationale: The correct action is to notify the healthcare provider in charge of this occurrence of paraphimosis. Paraphimosis is a urologic emergency where the foreskin is retracted and becomes tight, potentially impeding blood flow to the penis. It is crucial to seek medical intervention promptly to prevent complications.

4. In caring for an adolescent with severe abdominal pain due to appendicitis, where should the nurse identify as McBurney's point?

• A. Right lower quadrant
• B. Left lower quadrant
• C. Right upper quadrant
• D. Left upper quadrant

Correct answer: A

Rationale: McBurney's point is located in the right lower quadrant of the abdomen, specifically between the umbilicus and the anterior iliac crest. This point is significant in diagnosing appendicitis, as tenderness at McBurney's point is a classic sign of appendicitis and indicates inflammation near the appendix. Therefore, the correct answer is the 'Right lower quadrant.' Choices B, C, and D are incorrect because McBurney's point is not located in the left lower quadrant, right upper quadrant, or left upper quadrant of the abdomen.

5. A child is being assessed for Kawasaki disease. Which of the following findings should be expected?

• A. Decreased heart rate
• B. Dry, scaly skin
• C. Fever unresponsive to antipyretics
• D. Nontender cervical lymphadenopathy

Correct answer: C

Rationale: In Kawasaki disease, a child typically presents with a fever that is unresponsive to antipyretics because the disease is characterized by systemic inflammation. The persistent fever is a hallmark feature of the disease and can last for more than five days despite treatment with antipyretics.

Similar Questions