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. A 13-year-old client with type 1 diabetes is admitted to the hospital with a blood glucose level of 450 mg/dL. The client is lethargic and has fruity-smelling breath. What is the nurse’s priority action?

• A. Administer insulin as prescribed
• B. Start an IV infusion of normal saline
• C. Check the client’s urine for ketones
• D. Monitor the client’s vital signs

Correct answer: B

Rationale: The correct priority action for the nurse is to start an IV infusion of normal saline. The client's presentation with lethargy, fruity-smelling breath, and high blood glucose level indicates diabetic ketoacidosis (DKA). IV fluids are essential to correct dehydration and help stabilize the client's condition. Checking for ketones in the urine is important, but fluid replacement takes precedence to address the immediate risk of dehydration and electrolyte imbalances. Administering insulin is also a crucial intervention for DKA, but fluid resuscitation should first be initiated.

3. A 2-year-old child is admitted with severe dehydration due to gastroenteritis. Which assessment finding indicates that the child's condition is improving?

• A. Decreased heart rate.
• B. Sunken fontanelle.
• C. Increased urine output.
• D. Dry mucous membranes.

Correct answer: C

Rationale: Increased urine output is a positive sign indicating that the child's hydration status is improving. It suggests that the kidneys are functioning more effectively and able to excrete urine, which is a crucial indicator of improved hydration levels in a dehydrated patient. Decreased heart rate (Choice A) can be a sign of possible shock. A sunken fontanelle (Choice B) is a sign of dehydration. Dry mucous membranes (Choice D) are also indicative of dehydration.

4. What advice should be provided by the practical nurse to the mother of a school-age child with acute diarrhea and mild dehydration who is occasionally vomiting despite being given an oral rehydration solution (ORS)?

• A. Continue to give ORS frequently in small amounts.
• B. Alternate between ORS and carbonated beverages.
• C. Take the child to the hospital for intravenous fluids.
• D. Place the child NPO for the next eight to nine hours.

Correct answer: A

Rationale: The practical nurse should advise the mother to continue providing the oral rehydration solution (ORS) frequently in small amounts. It is essential to continue ORS administration to prevent dehydration, even if the child is occasionally vomiting. Small, frequent amounts of ORS help maintain hydration levels in children with acute diarrhea and mild dehydration.

5. The healthcare provider is evaluating the effects of thyroid therapy used to treat a 5-month-old with hypothyroidism. Which behavior indicates that the treatment has been effective?

• A. Laughs readily, turns from back to side.
• B. Has strong Moro and tonic neck reflexes.
• C. Keeps fists clenched, opens hands when grasping an object.
• D. Can lift head, but not chest when lying on abdomen.

Correct answer: A

Rationale: In infants, laughing readily and turning from back to side are indicative of normal development. These behaviors indicate that the thyroid therapy is effective, as they suggest the baby is achieving age-appropriate milestones. A 5-month-old infant should be able to laugh readily and turn from back to side, showing progress in motor and social development. Choices B, C, and D describe behaviors that are not specific to the expected developmental milestones of a 5-month-old. Strong Moro and tonic neck reflexes, clenched fists, and limited ability to lift the chest when lying on the abdomen are not necessarily indicative of the effectiveness of thyroid therapy for hypothyroidism.

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