Nursing Elites

1. The nurse is providing care for a pediatric client in the emergency department (ED) with a diagnosis of decreased level of consciousness (LOC) secondary to increased intracranial pressure (ICP). Which healthcare provider order should the nurse question?

• A. Passive range-of-motion exercises to promote hip flexion
• B. Oxygen at 2 L nasal cannula to maintain saturation above 95%
• C. Hourly vital signs and neurologic checks
• D. Elevate head of bed 30 degrees

Correct answer: A

Rationale: In a pediatric client with increased intracranial pressure (ICP) and decreased level of consciousness (LOC), passive range-of-motion exercises to promote hip flexion should be questioned as they can potentially increase intracranial pressure. This action may not be safe for the client's condition. The other options are appropriate interventions for managing a pediatric client with increased ICP and decreased LOC.

2. The healthcare provider is preparing medication instructions for a child who has undergone a kidney transplant and is prescribed cyclosporine. The parents ask the provider about the reason for the cyclosporine. Which rationale for this medication should the healthcare provider include in the response?

• A. Suppress rejection
• B. Decrease pain
• C. Improve circulation
• D. Boost immunity

Correct answer: A

Rationale: Cyclosporine is used to suppress the immune system and prevent rejection of the transplanted kidney. It helps to reduce the risk of the body attacking and rejecting the new organ. This medication is crucial in ensuring the success of the kidney transplant by keeping the immune system in check.

3. A healthcare professional is assessing an infant who has heart failure. Which of the following findings should the healthcare professional expect?

• A. Weight gain
• B. Bounding pulses
• C. Hyperactivity
• D. Increased urine output

Correct answer: A

Rationale: In infants with heart failure, one of the key manifestations is weight gain due to fluid retention. The heart's inability to pump effectively can lead to fluid buildup in the body, causing weight gain. Bounding pulses, hyperactivity, and increased urine output are not typically associated with heart failure in infants. Bounding pulses are associated with conditions like aortic regurgitation, hyperactivity can be a sign of other issues, and increased urine output is not a common finding in heart failure.

4. When teaching a parent of a 2-month-old infant with acute gastroenteritis who is bottle feeding, which of the following statements should the nurse include?

• A. Offer Pedialyte between formula feedings.
• B. Feed the infant every 6 hours.
• C. Give diluted apple juice if the infant becomes dehydrated.
• D. Switch to soy-based formula permanently.

Correct answer: A

Rationale: In the case of acute gastroenteritis in a 2-month-old infant who is bottle feeding, the nurse should recommend offering Pedialyte between formula feedings. This helps prevent dehydration and ensures that the infant receives essential electrolytes and fluids to aid in recovery. Pedialyte is specifically formulated to help replace lost fluids and electrolytes due to vomiting and diarrhea, making it a suitable choice for infants with gastroenteritis. Choice B is incorrect because infants with acute gastroenteritis should be fed more frequently to prevent dehydration. Choice C is incorrect as apple juice is not recommended for infants with gastroenteritis; Pedialyte or oral rehydration solutions are preferred. Choice D is incorrect because switching to soy-based formula permanently is not necessary for managing acute gastroenteritis; Pedialyte and continuing with the current formula are more appropriate.

5. A nurse is planning care for a school-age child who has thrombocytopenia. Which of the following interventions should the nurse include in the plan?

• A. Administer aspirin as needed for fever.
• B. Avoid venipunctures whenever possible.
• C. Encourage the child to participate in contact sports.
• D. Administer ibuprofen for pain.

Correct answer: B

Rationale: The correct answer is B: 'Avoid venipunctures whenever possible.' Thrombocytopenia is a condition characterized by a low platelet count, which can lead to an increased risk of bleeding. Venipunctures can cause bleeding in these patients; therefore, they should be avoided whenever possible. Choice A is incorrect because aspirin should be avoided in patients with thrombocytopenia as it can further increase the risk of bleeding due to its antiplatelet effects. Choice C is incorrect because participating in contact sports can also increase the risk of injury and bleeding in a child with thrombocytopenia. Choice D is incorrect as ibuprofen, like aspirin, can also increase the risk of bleeding and should be avoided in these patients.

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