Nursing Elites

1. A toddler presenting with a history of intermittent skin rashes, hives, abdominal pain, and vomiting that occurs after ingesting milk products arrives at the clinic accompanied by the parents. Which type of testing should the nurse educate the toddler's family about?

• A. Complete blood count
• B. Lactose tolerance test
• C. Skin allergy testing
• D. Serum immunoglobulin E

Correct answer: D

Rationale: The correct answer is D, Serum immunoglobulin E (IgE) testing. This test can help diagnose food allergies, including milk protein allergies, in toddlers presenting with symptoms like skin rashes, hives, abdominal pain, and vomiting after consuming milk products. Skin allergy testing is used for allergies but may not be suitable for this age group due to developmental factors. Lactose intolerance, which is different from a milk allergy, is assessed through a lactose tolerance test, not IgE testing. A complete blood count (CBC) would not provide specific information related to food allergies.

2. The healthcare provider is performing a physical assessment on a client who just had an endotracheal tube inserted. Which finding would call for immediate action by the healthcare provider?

• A. Breath sounds are audible bilaterally
• B. Mist is visible in the T-piece
• C. Pulse oximetry of 88
• D. Client is unable to verbalize

Correct answer: C

Rationale: A pulse oximetry reading of 88 indicates hypoxia, which is a serious condition requiring immediate intervention. Adequate oxygenation is crucial for the client's well-being. Choices A and B are normal findings after endotracheal intubation. Hearing bilateral breath sounds and seeing mist in the T-piece indicate proper functioning of the endotracheal tube. While choice D may indicate an issue with speaking due to the endotracheal tube, it is not as critical as the hypoxia indicated by the low pulse oximetry reading.

3. A client is experiencing acute bronchospasm. What is the nurse's priority intervention?

• A. Administer a nebulizer treatment of albuterol.
• B. Start an IV infusion of normal saline.
• C. Administer oxygen at 4L/min via nasal cannula.
• D. Position the client in a high Fowler's position.

Correct answer: A

Rationale: The correct answer is to administer a nebulizer treatment of albuterol. In acute bronchospasm, the priority intervention is to deliver a bronchodilator like albuterol to open the airways and improve breathing. Starting an IV infusion of normal saline (Choice B) may be necessary but not the priority in this situation. Administering oxygen at 4L/min via nasal cannula (Choice C) is important but not the first intervention for bronchospasm. Positioning the client in a high Fowler's position (Choice D) can help with breathing but is not the priority over administering a bronchodilator.

4. A child is admitted with bacterial meningitis. What assessment finding should the nurse monitor most closely?

• A. Monitor the client’s skin for rash and lesions.
• B. Monitor for signs of increased intracranial pressure.
• C. Monitor the client’s blood pressure closely.
• D. Monitor for changes in heart rate and rhythm.

Correct answer: B

Rationale: Correct Answer: B. Signs of increased intracranial pressure, such as changes in consciousness or pupil reactivity, are critical to monitor in children with bacterial meningitis to prevent complications. Monitoring the client’s skin for rash and lesions (Choice A) is not the priority in bacterial meningitis. While monitoring blood pressure (Choice C) is important, signs of increased intracranial pressure take precedence. Monitoring for changes in heart rate and rhythm (Choice D) is less specific to the condition and may not indicate worsening neurological status.

5. A client with heart failure is prescribed digoxin and reports nausea. What is the nurse's first action?

• A. Administer an anti-nausea medication as prescribed.
• B. Assess the client's digoxin level immediately.
• C. Assess the client’s apical pulse and hold the next dose if it's below 60 bpm.
• D. Instruct the client to reduce their fluid intake.

Correct answer: B

Rationale: When a client on digoxin reports nausea, it can be a sign of digoxin toxicity. The priority action for the nurse is to assess the client's digoxin level immediately. This assessment will help determine if the nausea is related to digoxin toxicity, requiring a dosage adjustment. Administering an anti-nausea medication (Choice A) does not address the underlying issue of potential digoxin toxicity. Assessing the client's apical pulse (Choice C) is important in general digoxin monitoring but not the first action when nausea is reported. Instructing the client to reduce fluid intake (Choice D) is not the initial response to nausea in a client taking digoxin.

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