Nursing Elites

1. A 4-month-old girl is brought to the clinic by her mother because she has had a cold for 2 to 3 days and woke up this morning with a hacking cough and difficulty breathing. Which additional assessment finding should alert the nurse that the child is in acute respiratory distress?

• A. Bilateral bronchial breath sounds.
• B. Diaphragmatic respiration.
• C. A resting respiratory rate of 35 breaths per minute.
• D. Flaring of the nares.

Correct answer: D

Rationale: Flaring of the nares is a clinical sign of acute respiratory distress in infants. It indicates an increased effort to breathe and is a crucial finding that requires immediate attention, as it signifies the child is having difficulty breathing and may be in respiratory distress. Choices A, B, and C are incorrect. Bilateral bronchial breath sounds may be present in conditions like pneumonia but do not specifically indicate acute respiratory distress. Diaphragmatic respiration is a normal breathing pattern and not a sign of distress. A resting respiratory rate of 35 breaths per minute in a 4-month-old infant is within the expected range, so it does not necessarily indicate acute respiratory distress.

2. During a follow-up clinical visit, a mother tells the nurse that her 5-month-old son, who had surgical correction for tetralogy of Fallot, has rapid breathing, often takes a long time to eat, and requires frequent rest periods. The infant is not crying while being held, and his growth is in the expected range. Which intervention should the nurse implement?

• A. Stimulate the infant to cry to produce cyanosis
• B. Auscultate the heart and lungs while the infant is held
• C. Evaluate the infant for failure to thrive
• D. Obtain a 12-lead electrocardiogram

Correct answer: B

Rationale: Auscultating the heart and lungs while the infant is held can provide important diagnostic information in assessing the cardiac and respiratory status of the infant who had surgical correction for tetralogy of Fallot. This intervention can help the nurse identify any abnormal heart or lung sounds, which may indicate complications or issues that need further evaluation or intervention.

3. The caregiver is providing discharge instructions to the parents of a 6-month-old infant who was hospitalized for bronchiolitis. Which statement by the parents indicates a correct understanding of the instructions?

• A. We should keep our baby away from people with colds
• B. We should continue giving the prescribed medication even if our baby seems better
• C. We should avoid giving solid foods to help with recovery
• D. We can place our baby to sleep on their back to help with breathing

Correct answer: A

Rationale: Keeping the infant away from people with colds is crucial to prevent the spread of respiratory infections, especially for infants recently hospitalized with bronchiolitis. This precaution helps protect the baby from further illnesses and promotes recovery. The other choices are incorrect because it is important to complete the prescribed medication course even if the baby seems better to ensure the infection is fully treated (Choice B). Solid foods are usually introduced around six months of age, so avoiding them entirely may not be necessary (Choice C). Placing the baby to sleep on their back is a safe sleep practice to prevent sudden infant death syndrome (SIDS) but may not directly help with breathing in the context of bronchiolitis (Choice D).

4. A 10-year-old child is admitted with diabetic ketoacidosis (DKA). Which laboratory value should the practical nurse (PN) anticipate?

• A. Elevated blood glucose.
• B. Decreased serum ketones.
• C. Low urine glucose.
• D. High bicarbonate levels.

Correct answer: A

Rationale: In a case of diabetic ketoacidosis (DKA), the primary feature is elevated blood glucose levels due to insulin deficiency. Additionally, ketones are increased in the blood and urine. Bicarbonate levels are usually low because of the metabolic acidosis that accompanies DKA. Therefore, the practical nurse should anticipate elevated blood glucose levels as a characteristic laboratory finding in a child admitted with DKA. Choice B is incorrect because serum ketones are increased in DKA. Choice C is incorrect because in DKA, urine glucose is typically high due to spillage of glucose into the urine. Choice D is incorrect because bicarbonate levels are usually low in DKA, not high.

5. A 2-year-old child with heart failure (HF) is admitted for replacement of a graft for coarctation of the aorta. Prior to administering the next dose of digoxin (Lanoxin), the nurse obtains an apical heart rate of 128 bpm. What action should the nurse take?

• A. Determine the pulse deficit.
• B. Administer the scheduled dose.
• C. Calculate the safe dose range.
• D. Review the serum digoxin level.

Correct answer: B

Rationale: Administering the scheduled dose is appropriate in this scenario since the heart rate of 128 bpm is within an acceptable range for a 2-year-old child with heart failure. Monitoring for signs of digoxin toxicity is important; however, the immediate action required is to administer the scheduled dose as prescribed based on the heart rate assessment.

Similar Questions