Nursing Elites

1. Which is the priority nursing assessment when providing care for an infant at risk for dehydration?

• A. Urine output
• B. Urine specific gravity
• C. Vital signs
• D. Daily weight

Correct answer: D

Rationale: The correct answer is Daily weight. Daily weight is a crucial assessment in infants at risk for dehydration because changes in weight can indicate fluid balance and dehydration status. It is essential to monitor daily weight to promptly identify and manage dehydration in infants.

2. A healthcare provider is planning care for a child with hyperkalemia. Which manifestation associated with the documented hyperkalemia requires immediate intervention by the healthcare provider?

• A. Hyperthermia
• B. Respiratory distress
• C. Seizures
• D. Cardiac arrhythmias

Correct answer: D

Rationale: In hyperkalemia, cardiac arrhythmias are the most critical and life-threatening manifestation that requires immediate intervention. Hyperkalemia can lead to dangerous heart rhythm disturbances, potentially resulting in cardiac arrest. Prompt treatment is essential to stabilize the heart rhythm and prevent life-threatening complications. Hyperthermia, respiratory distress, and seizures are not typically associated with hyperkalemia and should be addressed, but cardiac arrhythmias pose the most urgent risk to the patient's life.

3. Which physical assessment technique should be omitted when caring for a 2-year-old child diagnosed with Wilms' tumor?

• A. Performing range-of-motion exercises on lower extremities
• B. Palpating the abdomen
• C. Assessing for bowel sounds
• D. Percussing ankle and knee reflexes

Correct answer: B

Rationale: Palpating the abdomen should be omitted when caring for a 2-year-old child diagnosed with Wilms' tumor because it could disturb the tumor and potentially cause the malignancy to spread. The other assessment techniques are safe to perform and provide valuable information about the child's condition. Range-of-motion exercises help assess mobility and joint health, assessing for bowel sounds is important to monitor gastrointestinal function, and percussing ankle and knee reflexes can help evaluate neurological responses.

4. Which of the following is not considered a part of body language?

• A. Mannerisms
• B. Speech
• C. Posture
• D. Position

Correct answer: B

Rationale: Body language encompasses non-verbal communication cues such as mannerisms, posture, and position. Speech, although a form of communication, is not typically classified as part of body language. Body language mainly refers to gestures, facial expressions, and body movements, which convey messages non-verbally.

5. The patient is receiving a heparin infusion for the treatment of pulmonary embolism. Which assessment finding is most likely related to an adverse effect of heparin?

• A. HR of 60 bpm
• B. BP of 160/88
• C. Discolored urine
• D. Inspiratory wheezing

Correct answer: C

Rationale: The primary and most serious adverse effect of heparin is bleeding. However, discolored urine can indicate bleeding into the urinary tract, which is a potential adverse effect of heparin therapy. While changes in heart rate (HR) and blood pressure (BP) can occur due to various reasons, discolored urine specifically points towards a potential adverse effect related to heparin therapy.

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