Nursing Elites

1. Which menu choices for a child diagnosed with renal failure and experiencing hyperkalemia indicate the need for further instruction by the nurse?

• A. Carrots and green, leafy vegetables
• B. Spaghetti and meat sauce with breadsticks
• C. Hamburger on a bun and cherry gelatin
• D. Chips, cold cuts, and canned foods

Correct answer: A

Rationale: Carrots and green, leafy vegetables are high in potassium, which should be avoided in hyperkalemia. Therefore, this choice requires further instruction by the nurse to prevent exacerbating the child's condition.

2. During a well-child visit, a nurse is assessing a three-year-old toddler. Which of the following manifestations should the nurse report to the provider?

• A. Blood pressure 90/50
• B. Respiratory rate 45/min
• C. Weight 14.5 kg or 32 lb
• D. Heart rate 110/min

Correct answer: B

Rationale: A respiratory rate of 45/min is above the expected reference range for a 3-year-old toddler and may indicate respiratory dysfunction or acute respiratory distress. It is essential for the nurse to report this finding promptly to the healthcare provider for further evaluation and intervention.

3. A teacher states to the school nurse, 'I have a student who will often just stare at me for 15 seconds after asking a question; then the student blinks and asks me to repeat the question. Should I be concerned?' Which should the nurse include in the response to the teacher?

• A. The child has a crush on the teacher.
• B. The child has increased intracranial pressure.
• C. The child may have had a head injury.
• D. The child is experiencing absence seizures.

Correct answer: D

Rationale: Staring spells that end abruptly and are followed by normal activity are indicative of absence seizures. In absence seizures, a child may exhibit staring spells, brief loss of awareness, and lack of responsiveness, which can last for a few seconds. Choice A is incorrect because the behavior described is not associated with having a crush. Choice B is incorrect as increased intracranial pressure usually presents with other symptoms. Choice C is less likely as a head injury would typically manifest with additional signs beyond just staring and blinking.

4. Which factor will not promote play and playfulness in children?

• A. Novel toys
• B. Familiar peers
• C. Comfortable atmosphere
• D. Directive adults

Correct answer: D

Rationale: Directive adults can inhibit spontaneous play and creativity, which are essential for fostering playfulness in children. When adults are too directive, children may feel constrained and less likely to engage in imaginative and free play. Encouraging independence and allowing children to explore and create their play scenarios can enhance playfulness and creativity.

5. A patient is prescribed Lisinopril as part of the treatment plan for heart failure. Which finding indicates the patient is experiencing the therapeutic effect of this drug?

• A. Weight gain of 5 pounds in 1 week
• B. Potassium level of 3.5mEq/L
• C. Crackles in the lungs are no longer heard
• D. Jugular vein distention

Correct answer: C

Rationale: The correct answer is C. Lisinopril, an ACE inhibitor, promotes venous dilation, which helps reduce pulmonary congestion and peripheral edema. The absence of previously heard crackles in the lungs indicates effectiveness in reducing pulmonary congestion. Edema and jugular vein distention are signs of heart failure and would not indicate the therapeutic effect of Lisinopril. A potassium level of 3.5mEq/L is within the normal range and not directly related to the therapeutic effect of Lisinopril.

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