Nursing Elites

1. The nurse is caring for a 10-year-old diagnosed with acute glomerulonephritis. Which outcome is the priority for this child?

• A. Activity tolerance as evidenced by appropriate age-level activities being performed
• B. Absence of skin breakdown as evidenced by intact skin and absence of redness
• C. Maintaining adequate nutritional status as evidenced by stable weight without gain or loss
• D. Maintaining fluid balance as evidenced by a urine output of 1 to 2 ml/kg/hr

Correct answer: D

Rationale: In acute glomerulonephritis, maintaining fluid balance is the priority to prevent complications like fluid overload or dehydration. Monitoring urine output within the range of 1 to 2 ml/kg/hr is crucial in assessing renal function. While activity tolerance, skin integrity, and nutritional status are important aspects of care, fluid balance takes precedence due to its direct impact on the renal condition and overall health outcome for the child.

2. The nurse is assessing a client who is 2 days post-op following abdominal surgery. The client reports feeling something 'give way' in the incision site and there is a small amount of bowel protruding from the wound. What action should the nurse take first?

• A. Apply a sterile saline dressing to the wound
• B. Notify the healthcare provider
• C. Administer pain medication
• D. Cover the wound with an abdominal binder

Correct answer: A

Rationale: In this scenario, the nurse should first apply a sterile saline dressing to the wound. This action helps prevent infection and keeps the wound moist, which is crucial in promoting healing. Option B, notifying the healthcare provider, is important but should come after providing immediate wound care. Option C, administering pain medication, is not the priority when there is a small amount of bowel protruding from the wound. Option D, covering the wound with an abdominal binder, is not appropriate for this situation as it does not address the protruding bowel and potential risk for infection.

3. A client with a history of seizures is being discharged with a prescription for phenytoin (Dilantin). Which instruction should the nurse provide this client?

• A. Take the medication with meals
• B. Avoid alcohol while taking this medication
• C. Limit sodium intake
• D. Take the medication at bedtime

Correct answer: B

Rationale: The correct instruction is to advise the client to avoid alcohol while taking phenytoin. Alcohol can interact with phenytoin, making it less effective and leading to increased side effects. Taking the medication with meals (Choice A) may help reduce gastrointestinal upset but is not the most crucial instruction for this medication. Limiting sodium intake (Choice C) is not directly related to phenytoin therapy. Taking the medication at bedtime (Choice D) is not a standard instruction for phenytoin administration.

4. Several clients on a telemetry unit are scheduled for discharge in the morning, but a telemetry-monitored bed is needed immediately. The charge nurse should make arrangements to transfer which client to another medical unit?

• A. Learning to self-administer insulin injections after being diagnosed with diabetes mellitus
• B. Ambulatory following coronary artery bypass graft surgery performed six days ago
• C. Wearing a sling immobilizer following permanent pacemaker insertion earlier that day
• D. Experiencing syncopal episodes resulting from the dehydration caused by severe diarrhea

Correct answer: A

Rationale: The correct answer is A because transferring a stable client who is learning self-care, such as self-administering insulin injections after being diagnosed with diabetes mellitus, provides the needed telemetry-monitored bed without compromising the client's care. Choice B should not be transferred as the client is ambulatory following surgery and does not require telemetry monitoring. Choice C should not be transferred as the client is wearing a sling immobilizer following pacemaker insertion, which requires close monitoring. Choice D should not be transferred as the client is experiencing syncopal episodes due to severe dehydration, necessitating telemetry monitoring for immediate intervention.

5. A nurse is preparing to administer an intramuscular injection to a client. Which action should the nurse take to reduce the client's risk of injury?

• A. Use a 1-inch needle
• B. Select a large muscle for the injection
• C. Aspirate for blood return before injecting
• D. Massage the injection site

Correct answer: C

Rationale: The correct answer is to aspirate for blood return before injecting. This action helps ensure that the needle is not in a blood vessel, reducing the risk of injury. Using a 1-inch needle (Choice A) is a standard length for intramuscular injections but does not directly reduce the risk of injury. Selecting a large muscle for the injection (Choice B) is important for proper medication absorption but does not directly reduce the risk of injury. Massaging the injection site (Choice D) can help with medication absorption but does not reduce the risk of injury.

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