Nursing Elites

1. A 3-year-old is seen in the clinic and is diagnosed with an ear infection. The father reports that the child was awake several times during the night, crying. The PRIORITY nursing diagnosis for this child is:

• A. Sleep Pattern Disturbance related to pain.
• B. Pain related to ear infection.
• C. Altered Family Processes related to ill child.
• D. Ineffective Thermoregulation Related to Infection

Correct answer: B

Rationale: The priority nursing diagnosis for a child diagnosed with an ear infection and experiencing nighttime awakenings and crying would be 'Pain related to ear infection.' Pain management is crucial to ensure the child's comfort and well-being, which can also impact their sleep patterns. Addressing the pain as a priority can lead to improved sleep and overall recovery for the child.

2. When assisting ventilations in a 4-year-old child with a bag-valve mask, what should the EMT do?

• A. Deliver each breath over 2 to 3 seconds.
• B. Ensure the appropriate mask size is used.
• C. Block the pop-off valve if needed to achieve adequate chest rise.
• D. Reassess the pulse rate after 60 seconds.

Correct answer: C

Rationale: When assisting ventilations in a 4-year-old child with a bag-valve mask, the EMT should block the pop-off valve if needed to achieve adequate chest rise. This action helps ensure effective ventilation and adequate oxygenation in the child. Blocking the pop-off valve allows for better control over the volume of air delivered and can help maintain positive pressure in the airway, assisting in improving oxygenation and ventilation in the child. Choices A, B, and D are incorrect because delivering each breath over 2 to 3 seconds is a general guideline but may need adjustment based on patient response, ensuring the appropriate mask size is important but not the primary concern in this scenario, and reassessing the pulse rate is not directly related to the ventilation technique being discussed.

3. What should you do immediately upon delivery of a newborn's head?

• A. Suction the nose.
• B. Dry the face.
• C. Cover the eyes.
• D. Suction the mouth.

Correct answer: D

Rationale: Upon delivery of a newborn's head, the priority is to clear the airway to ensure proper breathing. Suctioning the mouth takes precedence over suctioning the nose or other actions to prevent potential airway obstruction. Choice D is the correct answer as it addresses the immediate need to maintain a clear airway for the newborn. Choices A, B, and C are not the correct actions to take at this moment as they do not directly address the crucial need to establish a clear airway for the newborn.

4. When educating the mother of a child with respiratory disease who needs a lot of fluids, the mother tells the nurse that when she offers her 24-month-old son juice, he always shakes his head and says, 'No'. The nurse suggests that the mother:

• A. Be firm and hand him the glass
• B. Distract him with some food
• C. Let him see that he is making her angry
• D. Offer him a choice of two things to drink

Correct answer: D

Rationale: Offering a choice can help the child feel more in control and willing to drink. By providing the child with options, the mother empowers him to make a decision, which can increase his willingness to drink fluids. This approach promotes a sense of autonomy and may lead to a more positive response from the child, ultimately contributing to better fluid intake, especially important for a child with a respiratory disease.

5. What should the nurse include in the insulin administration instruction for the parents of a child being discharged on insulin?

• A. Insert the needle and aspirate before injecting
• B. Inject insulin into the extremity to be exercised to improve absorption
• C. The muscles in the abdomen and thigh are the easiest for self-administration
• D. Clean the injection site with soap and water and avoid alcohol

Correct answer: C

Rationale: The correct answer is C because the muscles in the abdomen and thigh are the most suitable areas for self-administration of insulin due to consistent absorption. Choices A and B are incorrect as aspirating before injecting insulin is unnecessary, and injecting into an extremity to be exercised does not enhance absorption. Choice D is incorrect as alcohol should be used to clean the injection site instead of soap and water, which can cause skin irritation.

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