Nursing Elites

1. The healthcare provider is caring for a 6-year-old child diagnosed with glomerulonephritis. Which finding should the healthcare provider report promptly to the healthcare provider?

• A. Dark-colored urine
• B. Mild periorbital edema
• C. Blood pressure of 150/95 mm Hg
• D. Urine output of 250 mL in 24 hours

Correct answer: C

Rationale: Hypertension is a serious complication of glomerulonephritis, as it can lead to further renal damage. A blood pressure reading of 150/95 mm Hg is elevated and should be reported promptly to the healthcare provider for immediate management to prevent complications. Dark-colored urine can be a common symptom of glomerulonephritis due to blood in the urine but is not as urgent as managing hypertension. Mild periorbital edema can also be seen in glomerulonephritis but is not as concerning as elevated blood pressure. Urine output of 250 mL in 24 hours indicates oliguria, which is a concern, but addressing hypertension takes priority to prevent further renal damage.

2. 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.

3. What action should be taken by the healthcare provider for a child who has ingested a corrosive product?

• A. Induce vomiting using Ipecac to remove the corrosive agent.
• B. Administer vinegar or lemon juice to neutralize the caustic agent.
• C. Give activated charcoal to decontaminate the stomach.
• D. Telephone the poison control center and follow their advice.

Correct answer: D

Rationale: In cases of corrosive product ingestion, it is crucial to contact the poison control center for guidance. Inducing vomiting or attempting to neutralize the agent can lead to further harm. The poison control center professionals are trained to provide specific instructions tailored to the situation, ensuring the best possible outcome for the child. Therefore, the correct action is to call the poison control center for appropriate advice. Inducing vomiting can cause additional damage by re-exposing the esophagus and mouth to the corrosive substance. Administering vinegar or lemon juice is not recommended as it may worsen the situation by causing a chemical reaction. While activated charcoal can be useful in some cases of poisoning, it is not recommended for corrosive substances as it is ineffective in binding to them.

4. What action should the nurse take when a child presents with fever, sore throat, swollen red spots, and fluid-filled blisters?

• A. Obtain a fluid culture from the blisters
• B. Administer a fever-reducing medication
• C. Cover the drainage vesicles with a dressing
• D. Implement transmission precautions

Correct answer: D

Rationale: When a child presents with fever, sore throat, swollen red spots, and fluid-filled blisters, it may indicate a contagious viral infection. In such cases, implementing transmission precautions is crucial to prevent the spread of the infection to others in the pediatric clinic or community. Obtaining a fluid culture from the blisters (Choice A) may not be necessary at the initial stage without knowing the cause of the infection. Administering a fever-reducing medication (Choice B) may help manage symptoms but doesn't address the need for preventing transmission. Covering the drainage vesicles with a dressing (Choice C) may provide comfort to the child but does not directly address the risk of transmission to others.

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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