Nursing Elites

1. A 2-year-old child with a history of frequent ear infections is brought to the clinic by the parents who are concerned about the child’s hearing. What should the nurse do first?

• A. Ask the parents about the child’s speech development
• B. Perform a hearing test
• C. Inspect the child’s ears for drainage
• D. Refer the child to an audiologist

Correct answer: C

Rationale: The most appropriate initial action for the nurse to take is to inspect the child's ears for drainage. This step can provide immediate information on the presence of infection or fluid, which could be impacting the child's hearing. By assessing for drainage, the nurse can gather valuable initial data to determine the next course of action, such as further evaluation or treatment. Asking about speech development or referring to an audiologist would be secondary steps after assessing the physical condition of the ears. Performing a hearing test would also be premature without first examining the ears for any visible issues.

2. The parents of a 5-year-old child, recently diagnosed with celiac disease, are being educated by the healthcare provider. Which statement by the parents indicates a need for further teaching?

• A. We need to avoid giving our child any foods that contain wheat, barley, or rye
• B. Our child can still eat oats as long as they are labeled gluten-free
• C. We should read food labels carefully to check for hidden sources of gluten
• D. It’s okay for our child to have small amounts of gluten occasionally

Correct answer: D

Rationale: The correct answer is D. Children with celiac disease must strictly adhere to a gluten-free diet. Even small amounts of gluten can cause harm by triggering an immune response that damages the intestines. It is crucial for parents to understand that allowing their child to have small amounts of gluten occasionally is not safe and can lead to complications. Therefore, further teaching is needed to emphasize the importance of complete avoidance of gluten-containing foods for a child with celiac disease. Choices A, B, and C demonstrate understanding of the need to avoid gluten-containing foods and hidden sources of gluten, which are essential in managing celiac disease. Choice D is incorrect as it suggests a lax approach to the child's diet, which can be harmful in the case of celiac disease.

3. When should oral hygiene practices start for an infant according to the American Dental Association guidelines?

• A. There is no need to begin until after all of the child's baby teeth are in.
• B. You don't have to worry about that until your child can handle a toothbrush.
• C. You can begin now using toothpaste on a gauze pad and wiping the gums.
• D. Begin wiping the teeth with a washcloth and water when the first tooth appears.

Correct answer: D

Rationale: According to the American Dental Association guidelines, oral hygiene practices should start as soon as the first tooth appears. At this stage, using a soft cloth and water to clean the infant's gums and teeth is recommended to establish good oral hygiene habits early on and prevent dental issues. Choice A is incorrect as waiting until all baby teeth are in is too late for starting oral hygiene practices. Choice B is incorrect as it is essential to start oral hygiene before the child can handle a toothbrush. Choice C is incorrect as using toothpaste on a gauze pad is not recommended for infants with emerging teeth.

4. The nurse finds a 6-month-old infant unresponsive and calls for help. After opening the airway and finding the XXXX, the infant is still not breathing. What action should the nurse take next?

• A. Palpate the femoral pulse and check for regularity.
• B. Deliver cycles of 30 chest compressions and 2 breaths.
• C. Give two breaths that make the chest rise.
• D. Feel the carotid pulse and check for adequate breathing.

Correct answer: C

Rationale: In a scenario where a 6-month-old infant is unresponsive and not breathing after the airway is open, giving two breaths that make the chest rise is the appropriate action. This helps deliver oxygen to the infant's lungs and can help initiate breathing. Chest compressions are not recommended for infants as the first step in resuscitation. Checking pulses like the femoral or carotid pulse is not the priority when an infant is not breathing, as providing oxygen through breaths is essential.

5. A 3-year-old child with a high fever and sore throat is brought to the clinic. The nurse observes that the child is drooling and has difficulty swallowing. What is the nurse’s priority action?

• A. Administer antipyretic medication
• B. Prepare for emergency airway management
• C. Offer the child ice chips to suck on
• D. Assess the child’s hydration status

Correct answer: B

Rationale: In a 3-year-old child with drooling, difficulty swallowing, high fever, and sore throat, the nurse should prioritize preparing for emergency airway management. These signs may indicate epiglottitis, a condition that can quickly obstruct the airway, leading to respiratory distress and potentially fatal outcomes if not managed promptly. Administering antipyretic medication (Choice A) may be necessary later but is not the priority. Offering ice chips (Choice C) is contraindicated as the child has difficulty swallowing. Assessing hydration status (Choice D) is important but not the priority when the airway is at risk.

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