Nursing Elites

1. The nurse is caring for a child who has been diagnosed with attention deficit hyperactivity disorder (ADHD). What is the most important intervention for the nurse?

• A. Help the child enroll in a special education class.
• B. Allay any feelings of guilt the parents may have.
• C. Explain to the parents that medications are lifelong.
• D. Teach the parents how to set limits.

Correct answer: B

Rationale: The most important intervention for the nurse in caring for a child with ADHD is to allay any feelings of guilt the parents may have. Parents of children with ADHD often experience guilt or self-blame, thinking they are responsible for their child's condition. By addressing and alleviating these feelings, the nurse can support the parents in a crucial way. Choice A is not the most important intervention because enrolling the child in a special education class might be a consideration but does not address the emotional needs of the parents. Choice C is incorrect because stating that medications are lifelong may cause unnecessary distress to the parents. Choice D is also not the most important intervention as setting limits is important but not as critical as addressing parental guilt and emotions.

2. The nurse is providing postoperative care for a client who had a thyroidectomy. Which assessment finding requires immediate intervention?

• A. Hoarseness and weak voice
• B. Calcium level of 8.0 mg/dL (2.0 mmol/L)
• C. Heart rate of 110 beats per minute
• D. Difficulty swallowing

Correct answer: D

Rationale: Difficulty swallowing can indicate swelling or hematoma formation, which may compromise the airway and requires immediate intervention. Hoarseness and a weak voice are expected post-thyroidectomy due to manipulation of the laryngeal nerves but do not require immediate intervention. A calcium level of 8.0 mg/dL is within the normal range (8.5-10.5 mg/dL) and may not require immediate intervention. A heart rate of 110 beats per minute may be elevated due to stress or pain postoperatively, but it does not indicate an immediate threat to the airway.

3. A client is admitted to the medical unit during an exacerbation of systemic lupus erythematosus (SLE). It is most important to report which assessment finding to the healthcare provider?

• A. Low-grade fever.
• B. Muscle atrophy.
• C. Hematuria.
• D. Joint pain.

Correct answer: C

Rationale: Hematuria is the most important assessment finding to report to the healthcare provider in a client with SLE during an exacerbation. Hematuria indicates kidney involvement, a serious complication of SLE that requires prompt medical attention. While low-grade fever, muscle atrophy, and joint pain are symptoms that can occur in SLE, hematuria signifies potential renal damage, which is a critical concern in SLE exacerbations.

4. Based on the interpretation of this strip, what action should be implemented first?

• A. Call a code.
• B. Start CPR.
• C. Administer IV fluids.
• D. Apply oxygen.

Correct answer: A

Rationale: The correct answer is A: 'Call a code.' In the context of ventricular fibrillation (V-Fib), immediate defibrillation is crucial. Calling a code is the first step to activating the emergency response team, including individuals trained to provide defibrillation. Starting CPR (Choice B) may be necessary but should follow defibrillation. Administering IV fluids (Choice C) and applying oxygen (Choice D) are important interventions in cardiac arrest cases, but in V-Fib, the priority is defibrillation to restore normal heart rhythm.

5. The nurse is completing the preoperative assessment of a client who is scheduled for a laparoscopic cholecystectomy under general anesthesia. Which finding warrants notification of the HCP prior to proceeding with the scheduled procedure?

• A. Light yellow coloring of the client's skin and eyes.
• B. The client's blood pressure reading of 184/88 mm Hg.
• C. The client vomits 20 ml of clear yellowish fluid.
• D. The IV insertion site is red, swollen, and leaking IV fluid.

Correct answer: B

Rationale: The correct answer is B. A blood pressure reading of 184/88 mm Hg indicates hypertension, which can increase the risks associated with surgery. The healthcare provider should be notified to manage the blood pressure before proceeding with the scheduled procedure. Choices A, C, and D are incorrect: A, light yellow coloring of the client's skin and eyes may indicate jaundice, but it is not an immediate concern for the scheduled procedure; C, vomiting clear yellowish fluid may suggest bile reflux, but it does not pose an immediate risk to the procedure; D, red, swollen, and leaking IV insertion site indicates a local complication that requires intervention but does not have a direct impact on proceeding with the scheduled surgery.

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