Nursing Elites

1. Which pain assessment tool is most appropriate for a 3-month-old hospitalized with a fractured femur?

• A. FLACC scale
• B. Poker chip tool
• C. Number scale
• D. Visual analog scale

Correct answer: A

Rationale: The FLACC scale, which stands for Face, Legs, Activity, Cry, and Consolability, is specifically designed for nonverbal patients like infants and young children. It assesses pain based on observable behaviors such as facial expressions, leg movement, activity level, cry, and the ability to be consoled. In this case, a 3-month-old infant who is unable to communicate verbally would best be assessed using the FLACC scale to determine the level of pain experienced due to a fractured femur. The Poker chip tool, Number scale, and Visual analog scale are not suitable for nonverbal infants and young children as they rely on self-reporting or cognitive abilities that are not yet developed at this age.

2. Your assessment of a 5-year-old child reveals that he is unresponsive with a respiratory rate of 8 breaths/min and a heart rate of 50 beats/min. Treatment for this child should include:

• A. high-flow oxygen via non-rebreathing mask and rapid transport.
• B. assisted ventilation with a bag-mask device and rapid transport.
• C. positive-pressure ventilation, chest compressions, and rapid transport.
• D. back slaps and chest thrusts while attempting artificial ventilations.

Correct answer: C

Rationale: In a 5-year-old child who is unresponsive with severe bradycardia and bradypnea, the priority is to provide positive-pressure ventilation to support breathing and perform chest compressions to support circulation. This child is in cardiac arrest, and the recommended treatment according to pediatric basic life support guidelines involves a combination of positive-pressure ventilation and chest compressions to maintain oxygenation and circulation. Rapid transport to a medical facility for further advanced care is crucial in this critical situation. Choices A, B, and D are incorrect because high-flow oxygen via non-rebreathing mask, assisted ventilation with a bag-mask device, and back slaps with chest thrusts are not sufficient in a cardiac arrest situation where the child requires immediate positive-pressure ventilation and chest compressions to maintain oxygenation and circulation.

3. Upon assessing a newborn immediately after delivery, you note that the infant is breathing spontaneously and has a heart rate of 80 beats/min. What is the MOST appropriate initial management for this newborn?

• A. Assess the newborn's skin condition and color.
• B. Initiate positive-pressure ventilations.
• C. Start chest compressions and contact medical control.
• D. Provide blow-by oxygen with oxygen tubing.

Correct answer: B

Rationale: In a newborn with a heart rate below 100 beats/min, the most appropriate initial management is to initiate positive-pressure ventilations. This helps support the newborn's respiratory effort and oxygenation in the setting of a low heart rate, ensuring adequate oxygen supply to vital organs. Assessing the skin condition and color, starting chest compressions, or providing blow-by oxygen are not the priority in this scenario where respiratory support is crucial.

4. A clinic nurse reviews the record of a child just seen by a doctor and diagnosed with suspected aortic stenosis. The nurse expects to note documentation of which clinical manifestation specifically found in this disorder?

• A. Pallor
• B. Hyperactivity
• C. Exercise intolerance
• D. Gastrointestinal disturbances

Correct answer: C

Rationale: Aortic stenosis is a condition characterized by the narrowing of the aortic valve, leading to reduced blood flow from the heart to the body. This narrowing restricts the amount of oxygenated blood that can reach various tissues, including muscles. As a result, individuals with aortic stenosis may experience exercise intolerance, as their muscles may not receive an adequate oxygen supply during physical activity. This can manifest as fatigue, shortness of breath, and overall decreased exercise capacity. Pallor (choice A) is a pale appearance that may be seen in anemia or other conditions affecting blood flow but is not specific to aortic stenosis. Hyperactivity (choice B) and gastrointestinal disturbances (choice D) are not typically associated with aortic stenosis.

5. A 3-year-old female has had severe diarrhea and vomiting for 4 days. She is now unresponsive with rapid, shallow respirations and thready radial pulses. Her heart rate is 160 beats/min, and her oxygen saturation is 88%. You should:

• A. Ventilate her with a bag-valve mask.
• B. Start chest compressions.
• C. Administer high-flow oxygen via a non-rebreathing mask.
• D. Place her in the recovery position.

Correct answer: A

Rationale: In a pediatric patient presenting with unresponsiveness, rapid, shallow respirations, thready pulses, high heart rate, and low oxygen saturation, the priority is to ensure adequate oxygenation. Ventilating the child with a bag-valve mask is crucial in this scenario to support her breathing and improve oxygenation, as indicated by her low oxygen saturation and respiratory distress. Starting chest compressions is not indicated as the child has a pulse. Administering high-flow oxygen via a non-rebreathing mask may not be as effective as providing positive pressure ventilation with a bag-valve mask in this situation. Placing her in the recovery position is not appropriate when the child is unresponsive and in respiratory distress.

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