Nursing Elites

1. A 12-month-old child presents to the clinic for a well visit after missing several appointments. The child began her immunization schedule but has missed several follow-up appointments and doses of immunizations. What is the most appropriate nursing intervention?

• A. Administer initial immunizations from the beginning of the schedule.
• B. The child cannot receive missed immunizations if the schedule is not followed and will not be vaccinated.
• C. The child should only receive the missed doses of immunizations based on the catch-up schedule.
• D. The child should receive double-strength immunizations at this well visit.

Correct answer: C

Rationale: Children who began primary immunization at the recommended age but fail to receive all the doses do not need to begin the series again but should receive only the missed doses. The child may receive missed vaccinations on a catch-up schedule per CDC guidelines.

2. The Denver II is a test used to assess children. What does it evaluate?

• A. Behavior problems
• B. Developmental status
• C. Body mass index
• D. Infection likelihood

Correct answer: B

Rationale: The Denver II Developmental Screening Test is used to assess a child's development in four areas: personal-social, fine motor-adaptive, language, and gross motor skills. It helps identify children who may need further evaluation. Choice A, behavior problems, is incorrect as the Denver II primarily focuses on developmental milestones rather than behavior. Choice C, body mass index, is unrelated to the assessment of child development. Choice D, infection likelihood, is also not evaluated by the Denver II test.

3. The nurse is caring for an infant who had surgical repair of a tracheoesophageal fistula 24 hours ago. Gastrostomy feedings have not been started. What do nursing actions related to the gastrostomy tube include?

• A. Keep the tube clamped.
• B. Suction the tube as needed.
• C. Leave the tube open to gravity drainage.
• D. Secure the tube with tape.

Correct answer: C

Rationale: Leaving the gastrostomy tube open to gravity drainage prevents the accumulation of air and fluids, reducing the risk of complications such as vomiting or aspiration in the immediate postoperative period. Keeping the tube clamped or suctioning it can lead to pressure buildup, increasing the risk of complications. Securing the tube with tape is important but not the primary action related to the gastrostomy tube in this case.

4. A teen with asthma asks the nurse why it is hard to breathe during an asthma attack. The nurse explains that exposure to a “trigger” results in which of these manifestations?

• A. Bronchodilation, muscle relaxation, and decreased mucus production
• B. Air trapping and hypo-inflation of the alveoli
• C. Air trapping and decreased blood flow to the upper airway
• D. Bronchoconstriction, airway inflammation, and excess mucus production

Correct answer: D

Rationale: The correct answer is D. Asthma triggers cause bronchoconstriction, airway inflammation, and increased mucus production, leading to difficulty breathing. This combination of manifestations results in narrowing of the airways, making it hard for the individual to breathe effectively. Choices A, B, and C are incorrect because during an asthma attack, bronchodilation, muscle relaxation, and decreased mucus production do not occur. Instead, the airways constrict, become inflamed, and produce excess mucus, contributing to the breathing difficulties experienced by individuals with asthma.

5. What is the required number of milliliters of fluid needed per day for a 14-kg child?

• A. 800
• B. 1000
• C. 1200
• D. 1400

Correct answer: D

Rationale: The fluid requirement for a 14-kg child is approximately 100 mL/kg/day, so for a 14-kg child, the requirement is around 1400 mL/day.

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