Nursing Elites

1. The mother of a child with acute laryngotracheobronchitis (LTB) asks why her child must be kept NPO. Which response would be the most correct?

• A. The epinephrine given causes nausea and vomiting.
• B. The child is being hydrated with IV fluids.
• C. The child is not hungry.
• D. The child's rapid respirations pose a risk for aspiration.

Correct answer: D

Rationale: The correct answer is D because rapid respirations predispose to aspiration in a child with acute laryngotracheobronchitis. Choice A is incorrect because epinephrine does not directly relate to the need for NPO status. Choice B is incorrect as hydration with IV fluids is not the primary reason for keeping the child NPO. Choice C is incorrect as the child being hungry is not the main concern when keeping a child NPO in this situation.

2. Twelve hours following a unilateral total knee replacement, a client reports being unable to sleep because of severe incisional pain. What is the best initial nursing action?

• A. Administer a prescribed sedative.
• B. Reposition the client for comfort.
• C. Apply ice packs to the surgical site.
• D. Instruct the client in the use of the prescribed patient-controlled analgesia (PCA) pump.

Correct answer: D

Rationale: Instructing the client in the use of the PCA pump is the best initial nursing action for managing severe incisional pain after knee replacement surgery. The PCA pump allows the client to self-administer pain medication effectively, promoting better pain management. Administering a sedative may mask the pain temporarily but doesn't address the root cause. Repositioning the client for comfort or applying ice packs may provide some relief but doesn't address the need for effective pain control as the PCA pump does.

3. Following a bout of diarrhea, which foods should be offered to the school-age child?

• A. Apricots and peaches
• B. Chocolate milk
• C. Applesauce and milk
• D. Bananas and rice

Correct answer: D

Rationale: After rehydration, it is important to offer foods that are nonirritating to the bowel to the child. Bananas and rice are considered the best options as they are least likely to irritate the gastrointestinal tract. Apricots, peaches, and applesauce are fruits that may cause GI irritation, while milk, including chocolate milk, can also be irritating to the bowel. Therefore, the optimal choice for a child recovering from diarrhea would be bananas and rice.

4. What is a priority action for the nurse when caring for a client with suspected meningitis?

• A. Isolate the client in a private room
• B. Administer intravenous antibiotics
• C. Obtain a throat culture
• D. Perform a chest x-ray

Correct answer: B

Rationale: Administering intravenous antibiotics is the priority when caring for a client with suspected meningitis. The prompt administration of antibiotics is crucial to treat bacterial meningitis and prevent potential complications. Isolating the client in a private room may be necessary to prevent the spread of infection, but antibiotic administration takes precedence. Obtaining a throat culture and performing a chest x-ray are important diagnostic measures, but they do not address the immediate need for antibiotic therapy in suspected bacterial meningitis.

5. A client with diabetes mellitus presents with confusion and diaphoresis. What is the priority nursing action?

• A. Check the blood glucose level
• B. Administer insulin immediately
• C. Offer a high-protein snack
• D. Place the client in a supine position

Correct answer: A

Rationale: The correct answer is to check the blood glucose level. In a client with diabetes mellitus presenting with confusion and diaphoresis, it is important to assess the blood glucose level first to determine if the symptoms are due to hypoglycemia. Administering insulin immediately (Choice B) without knowing the blood glucose level can worsen the condition if the client is hypoglycemic. Offering a high-protein snack (Choice C) is not appropriate as the severity of hypoglycemia is unknown, and placing the client in a supine position (Choice D) is not the priority action for these symptoms.

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