Nursing Elites

1. Which nursing intervention is most important to include in the plan of care for a child with acute glomerulonephritis?

• A. Encourage fluid intake.
• B. Promote complete bed rest.
• C. Weigh the child daily.
• D. Administer vitamin supplements.

Correct answer: C

Rationale: Weighing the child daily is crucial in managing a child with acute glomerulonephritis as it helps in monitoring fluid retention, which is a key concern in this condition. Daily weight monitoring allows healthcare providers to assess changes in fluid status and adjust treatment accordingly. It is an essential component of the care plan to ensure the child's health status is closely monitored during the management of acute glomerulonephritis. Encouraging fluid intake (Choice A) is generally beneficial but may not be the priority in this case where fluid retention needs close monitoring. Promoting complete bed rest (Choice B) can be important but may not be the most critical intervention. Administering vitamin supplements (Choice D) may not directly address the immediate concerns related to fluid retention in acute glomerulonephritis.

2. Which nursing diagnosis is a priority for a 4-year-old child diagnosed with nephrotic syndrome?

• A. Impaired urinary elimination.
• B. Risk for infection.
• C. Fluid volume excess.
• D. Risk for impaired skin integrity.

Correct answer: C

Rationale: In a child with nephrotic syndrome, fluid volume excess is a priority nursing diagnosis due to the risk of edema and related complications. This patient may experience significant fluid retention, leading to edema, hypertension, and potential respiratory distress. Monitoring and managing fluid volume excess are crucial in preventing further complications and supporting the child's health during nephrotic syndrome. The other options are not the priority in this case. Impaired urinary elimination is not typically a primary concern in nephrotic syndrome. While infection is a risk due to compromised immunity, fluid volume excess poses a more immediate threat to the child's health. Risk for impaired skin integrity may be a concern secondary to edema, but addressing fluid volume excess takes precedence.

3. The parents of a 10-year-old child with newly diagnosed type 1 diabetes are being taught by the nurse about managing their child’s condition. Which statement by the parents indicates they need further teaching?

• A. We should rotate injection sites to prevent tissue damage
• B. Our child should avoid all sugary foods and drinks
• C. We will monitor blood glucose levels regularly
• D. Our child needs to wear a medical alert bracelet

Correct answer: B

Rationale: It is important for individuals with diabetes to manage their carbohydrate intake, including sugary foods and drinks, rather than completely avoiding them. Sugary foods should be consumed in moderation as part of a balanced diet to help maintain stable blood glucose levels.

4. An adolescent's mother calls the primary HCP's office to inquire about the results of her daughter's serum test that was drawn last week. Since it is the teenager's 18th birthday, how should the nurse respond to this mother's inquiry?

• A. Ask when the adolescent was last seen at the clinic
• B. Tell the mother to have the teenager call the clinic
• C. Provide the mother with the findings
• D. Explain that the information cannot be released without the 18-year-old's permission

Correct answer: D

Rationale: The correct response is to explain to the mother that the information cannot be released without the 18-year-old's permission. When an individual turns 18, they are legally considered an adult, and privacy laws mandate that their consent is required before sharing their medical information with others. It is crucial to respect the adolescent's autonomy and privacy rights. Choices A and C are incorrect because they involve disclosing the information without the individual's consent. Choice B is incorrect as it does not address the legal requirement for the adolescent's permission before sharing medical information.

5. What intervention should the nurse implement first for a male toddler brought to the emergency center approximately three hours after swallowing tablets from his grandmother’s bottle of digoxin (Lanoxin)?

• A. Administer activated charcoal orally
• B. Prepare gastric lavage
• C. Obtain a 12-lead electrocardiogram
• D. Give IV digoxin immune fab (Digibind)

Correct answer: D

Rationale: In cases of digoxin toxicity, IV digoxin immune fab (Digibind) is the antidote and should be administered first to counteract the effects of digoxin poisoning. This intervention is crucial in managing digoxin overdose and should be initiated promptly to improve patient outcomes. Activated charcoal and gastric lavage are not effective in treating digoxin poisoning and may not be beneficial at this stage. While obtaining an electrocardiogram is important to assess cardiac function, administering the antidote should take precedence to address the immediate life-threatening effects of digoxin toxicity.

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