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. What age-appropriate play activity should the practical nurse suggest to the parents of a 7-month-old infant to encourage visual stimulation?

• A. Play peek-a-boo.
• B. Play pat-a-cake.
• C. Imitate animal sounds.
• D. Show how to clap hands.

Correct answer: A

Rationale: The practical nurse should suggest playing peek-a-boo to the parents of a 7-month-old infant to encourage visual stimulation. Peek-a-boo is a suitable game for this age group as it helps develop visual tracking skills and the concept of object permanence. By covering and uncovering their face or a toy, the infant learns that things still exist even when they cannot be seen, promoting cognitive development and visual engagement.

3. Following admission for cardiac catheterization, the nurse is providing discharge teaching to the parents of a 2-year-old toddler with tetralogy of Fallot. What instruction should the nurse give the parents if their child becomes pale, cool, and lethargic?

• A. Encourage oral electrolyte solution intake
• B. Assist the child to a recumbent position
• C. Contact their healthcare provider immediately
• D. Provide a quiet time by holding or rocking the toddler

Correct answer: C

Rationale: If a child with tetralogy of Fallot becomes pale, cool, and lethargic, these symptoms may indicate a hypoxic episode or worsening condition. It is crucial to contact the healthcare provider immediately for further evaluation and management to ensure the child's safety and well-being. Option A is incorrect because electrolyte solution intake is not the immediate action needed for these symptoms. Option B is incorrect as positioning alone may not address the underlying issue. Option D is incorrect as providing a quiet time is not appropriate if the child is experiencing concerning symptoms that require prompt medical attention.

4. A mother brings her 3-month-old infant to the clinic, concerned about frequent vomiting after feeding. The practical nurse (PN) suspects gastroesophageal reflux (GER). Which recommendation should the PN provide to the mother?

• A. Feed the infant in a prone position.
• B. Provide larger, less frequent feedings.
• C. Keep the infant upright for 30 minutes after feeding.
• D. Offer only formula thickened with rice cereal.

Correct answer: C

Rationale: The correct recommendation for reducing symptoms of gastroesophageal reflux (GER) in infants is to keep the infant upright for 30 minutes after feeding. This position helps prevent the backflow of stomach contents, alleviating symptoms of reflux. Placing the infant in a prone position or providing larger, less frequent feedings may worsen symptoms by increasing the likelihood of regurgitation. Offering only formula thickened with rice cereal is not the first-line intervention for GER and should not be recommended initially.

5. When assessing a 10-year-old newly diagnosed with osteomyelitis, which information is most important for the nurse to obtain?

• A. Recent history of infection recurrences.
• B. Cultural heritage and beliefs.
• C. Family history of bone disorders.
• D. Increased fluid intake occurrences.

Correct answer: A

Rationale: In a 10-year-old with newly diagnosed osteomyelitis, the most important information for the nurse to obtain is the recent history of infection recurrences. This is crucial because osteomyelitis is an infection of the bone, and assessing for any recent recurrence of infections can help in determining the possible source of the osteomyelitis and guide the treatment plan accordingly. Choices B, C, and D are less relevant in the immediate assessment of a newly diagnosed case of osteomyelitis as they do not directly impact the current infection or treatment plan.

Similar Questions