Nursing Elites

1. What is an essential nursing action when caring for a young child with severe diarrhea?

• A. Maintain the IV.
• B. Take daily weights.
• C. Replace the lost calories.
• D. Promote perianal skin integrity.

Correct answer: D

Rationale: Promoting perianal skin integrity is crucial when caring for a young child with severe diarrhea as it helps prevent skin breakdown from the irritation caused by frequent stooling. Maintaining the IV (Choice A) may be necessary but is not directly related to managing perianal skin integrity. Taking daily weights (Choice B) is important for monitoring fluid status but not the priority when addressing perianal skin integrity. While replacing lost calories (Choice C) is essential, promoting perianal skin integrity takes precedence in preventing complications associated with skin breakdown.

2. What behavior is essential for preventing in a child postoperatively after undergoing heart surgery to repair defects associated with tetralogy of Fallot?

• A. Crying
• B. Coughing
• C. Straining at stool
• D. Unnecessary movement

Correct answer: C

Rationale: Preventing straining at stool is crucial postoperatively after heart surgery for tetralogy of Fallot to avoid increasing intrathoracic pressure and placing stress on the surgical site. This can help prevent complications and promote faster healing. While crying, coughing, and unnecessary movement are common postoperative behaviors, they are not specifically linked to worsening outcomes in this context. Straining at stool is particularly emphasized due to its potential to impact the surgical site and overall recovery process.

3. The nurse is implementing care for a school-age child admitted to the pediatric intensive care unit with diabetic ketoacidosis (DKA). Which prescribed intervention should the nurse implement first?

• A. Begin 0.9% saline solution intravenously as prescribed
• B. Administer regular insulin intravenously as prescribed
• C. Place child on a cardiac monitor
• D. Place child on a pulse oximetry monitor

Correct answer: A

Rationale: Initiating intravenous saline solution is the initial priority in managing diabetic ketoacidosis to address dehydration and electrolyte imbalances. Administering insulin without addressing dehydration first can lead to potential complications. While monitoring cardiac status and oxygen saturation are important, addressing the fluid and electrolyte imbalances takes precedence in the management of DKA.

4. What information should be included in the preoperative plan of care for an infant with myelomeningocele?

• A. Positioning the infant supine with a pillow under the buttocks
• B. Covering the sac with saline-soaked nonadhesive gauze
• C. Wrapping the infant snugly in a blanket
• D. Applying a diaper to prevent fecal soiling of the sac

Correct answer: B

Rationale: Covering the sac with saline-soaked nonadhesive gauze is essential in the preoperative care of an infant with myelomeningocele. This practice helps prevent infection and maintains moisture around the sac before surgery, promoting optimal healing outcomes. Positioning the infant supine with a pillow under the buttocks may be uncomfortable and unnecessary. Wrapping the infant snugly in a blanket does not address the specific care needs of the myelomeningocele. Applying a diaper over the sac can increase the risk of infection and should be avoided in this case.

5. The healthcare provider notes that a child has lost 8 pounds after 4 days of hospitalization for acute glomerulonephritis. This is most likely the result of

• A. poor appetite
• B. increased potassium intake
• C. reduction of edema
• D. restriction to bed rest

Correct answer: C

Rationale: In acute glomerulonephritis, weight loss is most likely due to the reduction of edema. Edema is a common symptom of glomerulonephritis, which causes fluid retention and swelling in the body. As treatment progresses and the condition improves, the reduction of edema leads to weight loss. Choices A, B, and D are incorrect as they do not directly address the underlying pathophysiology of acute glomerulonephritis and its impact on weight loss.

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