Nursing Elites

1. The nurse is assessing a 3-month-old infant who was brought to the clinic by the parents due to concerns about the infant’s feeding. The parents report that the infant has been vomiting after every feeding and has not gained any weight. What should the nurse assess first?

• A. Evaluate the infant’s feeding technique
• B. Check the infant’s hydration status
• C. Measure the infant’s abdominal circumference
• D. Review the infant’s growth chart

Correct answer: B

Rationale: Assessing hydration status is crucial in an infant who is vomiting frequently, as dehydration can quickly become a serious issue. In this scenario, the infant's inability to retain feeds and lack of weight gain may indicate a potential risk of dehydration, making it essential to prioritize checking the infant's hydration status to prevent complications. Evaluating the feeding technique (Choice A) could be important but is secondary to addressing potential dehydration. Measuring the abdominal circumference (Choice C) and reviewing the growth chart (Choice D) are not the priority in this situation where dehydration is a primary concern.

2. What is the best response for a two-year-old boy who begins to cry when the mother starts to leave?

• A. Let's wave bye-bye to mommy.
• B. Two-year-olds usually stop crying the minute the parent leaves.
• C. Now be a big boy. Mommy will be back soon.
• D. Let's wave bye-bye to mommy.

Correct answer: D

Rationale: The best response for a two-year-old boy who begins to cry when the mother starts to leave is to wave bye-bye to mommy. This action helps the child understand that the separation is temporary and gives him a sense of closure. Choice A is the correct answer. Choice B is incorrect as it generalizes the behavior of two-year-olds. Choice C may invalidate the child's feelings by telling him to 'be a big boy' instead of acknowledging his emotions and providing comfort.

3. A child with acute lymphocytic leukemia (ALL) who is receiving chemotherapy via a subclavian IV infusion has an oral temperature of 103 degrees. In assessing the IV site, the nurse determines that there are no signs of infection at the site. Which intervention is the most important for the nurse to implement?

• A. Obtain a specimen for blood cultures.
• B. Assess the CBC.
• C. Monitor the oral temperature every hour.
• D. Administer acetaminophen as prescribed.

Correct answer: A

Rationale: Obtaining a specimen for blood cultures is crucial in this situation as it helps identify the source of infection, if present, and guide appropriate treatment. This is important in a child with leukemia receiving chemotherapy to prevent potential complications and ensure timely intervention. Assessing the CBC may provide overall information on the child's condition but may not specifically identify a potential infection. Monitoring the oral temperature is important but obtaining blood cultures takes precedence in this scenario. Administering acetaminophen can help reduce fever but does not address the need to identify a possible infection source.

4. In a 12-year-old child with a history of epilepsy brought to the emergency department after experiencing a 10-minute seizure, what is the nurse’s priority intervention?

• A. Administer oxygen
• B. Administer antiepileptic medication as prescribed
• C. Monitor the child’s vital signs
• D. Check the child’s blood glucose level

Correct answer: B

Rationale: Administering antiepileptic medication as prescribed is the priority intervention in a child with a history of epilepsy who experienced a prolonged seizure. This action is crucial to stop the seizure and prevent further complications associated with prolonged seizure activity. Administering oxygen may be necessary, but the priority is to stop the seizure. Monitoring vital signs and checking blood glucose levels are important but secondary to administering antiepileptic medication to manage the seizure.

5. A 16-year-old male client who has been treated in the past for a seizure disorder is admitted to the hospital. Immediately after admission, he begins to have a grand mal seizure. Which action should the nurse take?

• A. Obtain assistance in holding him to prevent injury.
• B. Observe him carefully.
• C. Call a CODE.
• D. Place a padded tongue blade between the teeth.

Correct answer: B

Rationale: During a grand mal seizure, the priority action for the nurse is to ensure the safety of the client. Observing the client carefully allows the nurse to monitor the seizure activity, the client's breathing, and any signs of distress without interfering with the seizure process. Restraining the client or placing objects in the mouth can lead to injury and should be avoided. Calling a CODE is not appropriate for a seizure as it is a normal response to the client's condition.

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