Nursing Elites

1. The caregiver is caring for a 2-month-old infant with a diagnosis of bronchiolitis. Which assessment finding would be most concerning to the caregiver?

• A. Nasal flaring and grunting
• B. Coughing and wheezing
• C. Poor feeding and irritability
• D. Increased respiratory rate

Correct answer: A

Rationale: Nasal flaring and grunting are indicative of respiratory distress, suggesting the infant is having difficulty breathing. This finding requires immediate attention as it signifies a more severe respiratory compromise compared to the other symptoms listed.

2. The caregiver is caring for a 3-year-old child with a diagnosis of gastroenteritis. The child has had several episodes of vomiting and diarrhea over the past 24 hours. What is the caregiver's priority assessment?

• A. Monitor the child's weight
• B. Assess the child's hydration status
• C. Evaluate the child's nutritional intake
• D. Check the child's temperature

Correct answer: B

Rationale: The correct answer is B: Assess the child's hydration status. In children with gastroenteritis, assessing hydration status is crucial as they are at risk of dehydration due to vomiting and diarrhea. Monitoring hydration helps prevent complications and guides appropriate interventions to maintain the child's fluid balance. Monitoring the child's weight (Choice A) is not the priority in this situation compared to assessing hydration status. Evaluating nutritional intake (Choice C) is important but not the priority when the child is at risk of dehydration. Checking the child's temperature (Choice D) is relevant but not the priority over assessing hydration status in a child with gastroenteritis.

3. Which drink choice on a hot day indicates that a teenager with sickle cell anemia understands dietary considerations related to the disease?

• A. Milkshake
• B. Iced tea
• C. Diet cola
• D. Lemonade

Correct answer: D

Rationale: Lemonade is the correct choice for a teenager with sickle cell anemia as it provides hydration without caffeine, which is important for individuals with this condition. Caffeine can lead to dehydration, vasoconstriction, and potentially worsen symptoms in sickle cell anemia patients. Milkshake (choice A) may contain dairy, which can be high in fat and may not be the best choice for someone with sickle cell anemia. Iced tea (choice B) and diet cola (choice C) both contain caffeine, which should be avoided by individuals with sickle cell anemia due to its dehydrating effects.

4. A 10-year-old child with hemophilia is admitted to the hospital with joint pain and swelling. What should the healthcare provider do first?

• A. Apply ice to the affected joint
• B. Administer pain medication
• C. Elevate the affected limb
• D. Administer factor VIII as prescribed

Correct answer: D

Rationale: Administering factor VIII as prescribed is the priority intervention for a child with hemophilia experiencing joint pain and swelling. Hemophilia is a genetic disorder that impairs the blood's ability to clot properly, leading to prolonged bleeding. Factor VIII replacement therapy is essential as it helps restore the missing clotting factor in patients with hemophilia, thereby aiding in clot formation and preventing further bleeding. Applying ice, administering pain medication, or elevating the limb may be supportive measures but addressing the underlying cause by providing factor VIII therapy takes precedence in managing hemophilia-related joint pain and swelling.

5. What is the priority intervention for a 16-year-old client with a history of depression who is brought to the emergency department after taking an overdose of acetaminophen?

• A. Administer activated charcoal
• B. Place the client on continuous cardiac monitoring
• C. Prepare for gastric lavage
• D. Administer N-acetylcysteine as prescribed

Correct answer: D

Rationale: The priority intervention for a client who has taken an acetaminophen overdose is to administer N-acetylcysteine promptly. N-acetylcysteine is the antidote for acetaminophen overdose and helps prevent liver damage. Activated charcoal may be used in certain cases, but N-acetylcysteine takes precedence as it directly counteracts the toxic effects of acetaminophen. Continuous cardiac monitoring and gastric lavage are not the priority interventions for acetaminophen overdose. Administering N-acetylcysteine is crucial to prevent liver damage and address the overdose, making it the most urgent action in this scenario.

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