Nursing Elites

1. A patient's chart indicates a history of ketoacidosis. Which of the following would you not expect to see with this patient if this condition were acute?

• A. Vomiting
• B. Extreme Thirst
• C. Weight gain
• D. Acetone breath smell

Correct answer: C

Rationale: In acute ketoacidosis, a patient typically experiences rapid weight loss due to the body burning fat and muscle for energy in the absence of sufficient insulin. Therefore, weight gain would not be expected. Vomiting may occur due to the metabolic disturbances associated with ketoacidosis. Extreme thirst is a common symptom as the body tries to compensate for dehydration. Acetone breath smell is a classic sign of ketoacidosis as acetone is one of the ketones produced during this condition.

2. The nurse is creating a plan of care for a 10-year-old child diagnosed with acute glomerulonephritis. What is the priority nursing intervention?

• A. Promoting bed rest
• B. Restricting oral fluids
• C. Allowing the child to play
• D. Encouraging visits from friends

Correct answer: A

Rationale: During the acute phase of glomerulonephritis, promoting bed rest is a priority to reduce stress on the kidneys and promote recovery. As the condition improves, activity can be gradually increased. Restricting oral fluids is not recommended as maintaining adequate hydration is crucial. Allowing the child to play quietly can be beneficial but is not the priority over rest during the acute phase. Encouraging visits from friends may disrupt the rest needed for recovery, so visitors should be limited.

3. Which response by the nurse best explains the purpose of ranitidine (Zantac) for a patient admitted with bleeding esophageal varices?

• A. The medication will reduce the risk of aspiration.
• B. The medication will inhibit the development of gastric ulcers.
• C. The medication will prevent irritation of the enlarged veins.
• D. The medication will decrease nausea and improve appetite.

Correct answer: C

Rationale: The correct answer is: 'The medication will prevent irritation of the enlarged veins.' Esophageal varices are dilated submucosal veins. The therapeutic action of H2-receptor blockers in patients with esophageal varices is to prevent irritation and bleeding from the varices caused by reflux of acidic gastric contents. While ranitidine can decrease the risk of peptic ulcers, reduce nausea, and help prevent aspiration pneumonia, the primary purpose of H2-receptor blockade in this patient is to prevent irritation and bleeding from the varices, not the other listed effects.

4. Clinical manifestations of asthma include:

• A. Decreased expiratory time
• B. Increased peak expiratory flow
• C. Increased use of accessory muscles
• D. Increased oxygen saturation

Correct answer: C

Rationale: Clinical manifestations of asthma include increased use of accessory muscles, increased expiratory time, increased peak expiratory flow, and decreased oxygen saturation. Choice A, 'Decreased expiratory time,' is incorrect because asthma typically presents with increased expiratory time due to airway obstruction. Choice B, 'Increased peak expiratory flow,' is incorrect as asthma commonly leads to decreased peak expiratory flow due to airway constriction. Choice D, 'Increased oxygen saturation,' is incorrect because asthma exacerbations often result in decreased oxygen saturation levels.

5. The nurse is caring for an infant with cryptorchidism. The nurse anticipates that the most likely diagnostic study to be prescribed would be the one that assesses which item?

• A. Babinski reflex
• B. DNA synthesis
• C. Urinary function
• D. Chromosomal analysis

Correct answer: C

Rationale: Cryptorchidism, also known as undescended testes, may be caused by hormonal deficiency, intrinsic testicular abnormality, or a structural problem. Diagnostic studies for cryptorchidism typically involve assessing urinary function because the kidneys and testes originate from the same embryonic tissue. The Babinski reflex is a test for neurological function and is not relevant to evaluating cryptorchidism. DNA synthesis and chromosomal analysis are not commonly used diagnostic tests for cryptorchidism, as they are unrelated to the disorder's etiology or presentation.

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