Nursing Elites

1. The healthcare provider is assessing an infant brought to the clinic due to diarrhea. The infant is alert but has dry mucous membranes. Which additional assessment data indicates to the healthcare provider that the infant is experiencing an early to moderate stage of dehydration?

• A. Bradycardia
• B. Tachycardia
• C. Increased blood pressure
• D. Normal fontanels

Correct answer: B

Rationale: Tachycardia is a common early sign of dehydration in infants, especially when presenting with dry mucous membranes and diarrhea. The increased heart rate is the body's compensatory mechanism to maintain cardiac output in response to dehydration. Bradycardia, increased blood pressure, and normal fontanels are not typically associated with early to moderate dehydration in infants.

2. The mother of a 5-year-old child taking prednisone for nephrotic syndrome tells the nurse he needs to get immunizations to enter kindergarten. What does the nurse clarify about receiving immunizations while on prednisone?

• A. Can interfere with the treatment for nephrosis.
• B. Require that the child have antibiotic coverage.
• C. Can be given in smaller, divided doses.
• D. Should be delayed.

Correct answer: D

Rationale: No vaccinations or immunizations should be administered while the disease is active and during immunosuppressive therapy.

3. Before administering a live virus vaccine to a patient taking a glucocorticoid medication, what action should the nurse take?

• A. Continue screening and administer the vaccine if appropriate
• B. Note the contraindication but administer the vaccine regardless
• C. Note the contraindication and clarify the order with the healthcare provider
• D. Withhold the vaccine and inform the department of health

Correct answer: C

Rationale: The correct action for the nurse to take when a patient on glucocorticoid medication is to note the contraindication and clarify the order with the healthcare provider. Glucocorticoids can suppress the immune response, potentially reducing the effectiveness of vaccines. Therefore, it is crucial to consult with the healthcare provider to assess the risks and benefits of administering a live virus vaccine in such circumstances. Administering a live virus vaccine to a patient taking glucocorticoids can increase the risk of developing a viral infection, making it essential to seek guidance from the healthcare provider before proceeding.

4. The patient taking spironolactone (Aldactone) makes a statement indicating effective teaching. Which statement shows understanding of the teaching?

• A. I will use salt substitutes to lower my sodium intake
• B. I will increase my intake of foods that are high in potassium
• C. I will call my doctor if I begin having menstrual irregularities
• D. I will take this medication at bedtime each evening

Correct answer: C

Rationale: The correct answer is C because spironolactone is a potassium-sparing diuretic that can cause endocrine effects like menstrual irregularities. Therefore, the patient recognizing the need to report such changes indicates effective teaching. Choices A and B are incorrect as salt substitutes and high-potassium foods should be avoided with spironolactone. Choice D is also incorrect because diuretics, including spironolactone, are ideally taken in the morning to prevent disturbances in sleep due to nocturia.

5. The healthcare provider is assessing abdominal girth for a pediatric client who presents with abdominal distension. Which nursing action is appropriate?

• A. Measuring the girth just below the umbilicus
• B. Measuring the girth just below the sternum
• C. Measuring the girth just above the pubic bone
• D. Measuring the girth around the largest portion of the abdomen

Correct answer: D

Rationale: Measuring the girth around the largest portion of the abdomen ensures accurate assessment and tracking of abdominal distension. This method provides a more comprehensive measurement and helps healthcare providers monitor changes effectively.

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