Nursing Elites

1. What is a clinical manifestation of acetaminophen poisoning?

• A. Hyperpyrexia
• B. Hepatic involvement
• C. Severe burning pain in stomach
• D. Drooling and inability to clear secretions

Correct answer: B

Rationale: Acetaminophen poisoning primarily affects the liver, leading to hepatic involvement, which may present as jaundice, liver failure, or elevated liver enzymes. Hyperpyrexia, severe pain, and drooling are more associated with other types of poisoning.

2. A child with nephrotic syndrome is severely edematous. The primary healthcare provider has placed the child on bed rest. Which nursing intervention should be included in the plan of care?

• A. Monitor blood pressure every 30 minutes.
• B. Reposition the child every two hours.
• C. Limit visitors.
• D. Encourage fluids.

Correct answer: B

Rationale: Repositioning the child every two hours is essential to prevent pressure ulcers and promote circulation, especially when the child is on bed rest and experiencing severe edema. Monitoring blood pressure is important but does not need to be done every 30 minutes unless indicated. Limiting visitors and encouraging fluids are not directly related to managing edema and preventing complications from immobility. Therefore, choice B is the most appropriate nursing intervention in this scenario.

3. The nurse is admitting a 9-year-old child with hemolytic uremic syndrome. What clinical manifestations should the nurse expect to observe? (Select all that apply.)

• A. All are correct
• B. Anorexia
• C. Hypertension
• D. Purpura

Correct answer: A

Rationale: Hemolytic uremic syndrome (HUS) typically presents with hematuria, anorexia, hypertension, and purpura due to the hemolytic anemia, thrombocytopenia, and renal failure that characterize this condition.

4. The nurse is caring for a very low-birth-weight (VLBW) infant with a peripheral intravenous infusion. What nursing considerations regarding infiltration should be included in planning IV care?

• A. Infiltration is not solely related to the activity level of VLBW infants.
• B. Continuous infusion pumps do not always stop automatically when infiltration occurs.
• C. Hypertonic solutions can cause severe tissue damage if infiltration occurs.
• D. The infusion site should be checked regularly to prevent infiltration-related complications.

Correct answer: C

Rationale: Hypertonic solutions can damage tissues if they leak from the vein due to infiltration. It is crucial to monitor for this complication to prevent severe tissue damage. Infiltration is not solely related to the activity level of VLBW infants; it can occur due to various reasons such as vein condition, catheter placement, and fluid type. Continuous infusion pumps may not always detect infiltration, as they typically alarm for pressure changes but not all infiltration instances. Checking the infusion site regularly, preferably hourly, is essential to prevent complications like tissue damage from extravasations, fluid overload, and dehydration.

5. An effective means of establishing rapport with the hospitalized pre-schooler is through:

• A. Lengthy discussion
• B. Explanation with drawings and models
• C. Play
• D. Silence

Correct answer: C

Rationale: Play is an effective way to communicate and build rapport with young children, especially pre-schoolers. It helps them feel comfortable, express themselves, and establish a connection with the caregiver. Lengthy discussions may not be suitable for their age and attention span, while explanation with drawings and models can enhance communication but may not engage them as effectively as play. Silence, on the other hand, may create a sense of unease or lack of interaction for pre-schoolers.

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