Nursing Elites

1. The nurse empties the nasogastric suction collection canister of a client who had a bowel resection the previous day and notes that 1,000 mL of gastric secretions were collected in the last 4 hours. The nurse should assess the client for symptoms of which related problem?

• A. Respiratory acidosis.
• B. Metabolic alkalosis.
• C. Hypoglycemia.
• D. Hyperkalemia.

Correct answer: B

Rationale: The correct answer is B: Metabolic alkalosis. Loss of gastric secretions can lead to metabolic alkalosis due to the loss of hydrochloric acid. This can result in an increase in blood pH levels. Respiratory acidosis (choice A) is caused by retention of carbon dioxide, not related to the loss of gastric secretions. Hypoglycemia (choice C) is a low blood sugar level and is not directly related to the loss of gastric secretions. Hyperkalemia (choice D) is an elevated potassium level in the blood and is not typically associated with the loss of gastric secretions.

2. A 2-year-old child with laryngotracheobronchitis (LTB) is fussy and restless in the oxygen tent. The oxygen level in the tent is 25%, and blood gases are normal. What would be the correct action by the nurse?

• A. Restrain the child in the tent and notify the health care provider.
• B. Increase the oxygen concentration in the tent.
• C. Take the child out of the tent and into the playroom.
• D. Ask the mother for help in comforting the child.

Correct answer: B

Rationale: The child with LTB should be placed in the mist tent with 30% oxygen. Restlessness is caused by poor oxygenation. The child should not be taken out of the oxygenated tent. While the mother could be asked to help comfort the child, and the health care provider may be notified, the priority is to set the oxygen at the correct level.

3. The nurse instructs the mother of a child with a ventricular septal defect that she can expect the child to become cyanotic when the child does what?

• A. Experiences an elevation in temperature.
• B. Sleeps on the left side.
• C. Cries vigorously.
• D. Eats.

Correct answer: C

Rationale: The correct answer is C: Cries vigorously. When the child cries vigorously, it increases the pressure in the right ventricle, allowing unoxygenated blood to enter the circulating volume, leading to cyanosis. This occurs due to the shunting of blood from the right side of the heart to the left side through the ventricular septal defect. Choices A, B, and D are incorrect because they do not directly impact the pressure in the right ventricle, which is crucial in causing cyanosis in this scenario.

4. The nurse explains to the parents of a child with developmental hip dysplasia that the application of a Pavlik harness is necessary. In what position will the harness hold the child's femurs?

• A. Abduction
• B. Adduction
• C. Flexion
• D. Extension

Correct answer: A

Rationale: The correct answer is A: Abduction. The use of the Pavlik harness is to maintain the hips in abduction for 4 to 6 months to treat developmental hip dysplasia. This position helps in stabilizing the hip joint and promoting proper growth and development. Choices B, C, and D are incorrect because the Pavlik harness specifically aims to hold the child's femurs in abduction, not adduction, flexion, or extension.

5. Fluids are restricted to 1500 ml/day for a male client with AKI. He is frustrated and complaining of constant thirst, and the nurse discovers that the family is providing the client with additional fluids. What intervention should the nurse implement?

• A. Remove all sources of liquids from the client's room
• B. Allow family to give the client a measured amount of ice chips
• C. Restrict family visiting until the client's condition is stable
• D. Provide the client with oral swabs to moisten his mouth

Correct answer: D

Rationale: In this scenario, the nurse should provide the client with oral swabs to moisten his mouth. This intervention helps alleviate the client's thirst without increasing fluid intake, which is essential in managing AKI. Removing all sources of liquids from the client's room (Choice A) may not address the underlying issue of thirst and could lead to increased frustration. Allowing the family to give the client ice chips (Choice B) would add to the client's fluid intake, contradicting the restriction. Restricting family visiting (Choice C) is not necessary and does not directly address the client's thirst.

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