Nursing Elites

1. Nurses should be alert for increased fluid requirements in which circumstance?

• A. Fever
• B. Mechanical ventilation
• C. Congestive heart failure
• D. Increased intracranial pressure

Correct answer: A

Rationale: Fever increases metabolic rate, leading to insensible water loss, thus requiring increased fluid intake. Mechanical ventilation, CHF, and increased intracranial pressure generally require fluid restriction rather than increased fluid intake.

2. What type of shock is characterized by a hypersensitivity reaction causing massive vasodilation and capillary leaks, which may occur with drug or latex allergy?

• A. Neurogenic shock
• B. Cardiogenic shock
• C. Hypovolemic shock
• D. Anaphylactic shock

Correct answer: D

Rationale: Anaphylactic shock is a severe allergic reaction that causes massive vasodilation and increased capillary permeability, leading to rapid fluid shifts and circulatory collapse if not treated promptly. Neurogenic, cardiogenic, and hypovolemic shocks have different etiologies.

3. What recommendation should the nurse make to prevent urinary tract infections (UTIs) in young girls?

• A. Avoid public toilet facilities
• B. Limit long baths as much as possible
• C. Cleanse the perineum with water after voiding
• D. Ensure clear liquid intake of 2 L/day

Correct answer: C

Rationale: Proper perineal hygiene, including cleansing with water after voiding, is crucial in preventing UTIs in young girls. Avoiding public toilets and limiting baths are less effective than proper hygiene practices.

4. A child with acute gastrointestinal bleeding is admitted to the hospital. The nurse observes which sign or symptom as an early manifestation of shock?

• A. Restlessness
• B. Rapid capillary refill
• C. Increased temperature
• D. Increased blood pressure

Correct answer: A

Rationale: Restlessness is an early sign of shock due to decreased perfusion and oxygenation to the brain. This symptom requires immediate attention to prevent the progression to more severe stages of shock. Rapid capillary refill (Choice B) is not typically an early sign of shock but rather a sign of adequate perfusion. Increased temperature (Choice C) may occur in later stages of shock due to the body's response to stress. Increased blood pressure (Choice D) is not an early sign of shock; in fact, blood pressure tends to decrease in shock as a compensatory mechanism.

5. The parent of a child hospitalized with acute glomerulonephritis asks the nurse why blood pressure readings are being taken so often. What knowledge should influence the nurse's reply?

• A. The antibiotic therapy contributes to labile blood pressure values.
• B. Hypotension leading to sudden shock can develop at any time.
• C. Acute hypertension is a concern that requires monitoring.
• D. Blood pressure fluctuations indicate that the condition has become chronic.

Correct answer: C

Rationale: Acute hypertension is a common complication of acute glomerulonephritis, requiring frequent monitoring to prevent complications such as encephalopathy or heart failure. Blood pressure fluctuations can occur but are not necessarily indicative of chronic disease.

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