Nursing Elites

1. A 5-year-old child is brought to the emergency department with severe abdominal pain and vomiting. The child’s parent reports that the pain started suddenly and is located in the lower right abdomen. What should the nurse do first?

• A. Administer pain medication
• B. Notify the healthcare provider immediately
• C. Start an IV line for fluid administration
• D. Obtain a complete blood count

Correct answer: B

Rationale: The correct answer is to notify the healthcare provider immediately. The child's presentation of sudden, severe abdominal pain in the lower right abdomen is highly concerning for appendicitis, a medical emergency. Promptly notifying the healthcare provider is crucial for further evaluation and management. Administering pain medication as the first action might mask symptoms and delay diagnosis. Starting an IV line for fluid administration and obtaining a complete blood count are important interventions but should come after healthcare provider notification.

2. The caregiver discovers a 6-month-old infant unresponsive and calls for help. After opening the airway and finding the infant is still not breathing, what action should the caregiver take?

• A. Palpate 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: Providing two breaths that make the chest rise is the correct action in this situation. This helps to deliver oxygen to the infant's lungs and body, which is crucial in a situation where the infant is not breathing. Chest rise indicates successful ventilation, and it is an essential step in pediatric resuscitation, especially for infants. Choices A, B, and D are incorrect because palpating the femoral pulse, delivering chest compressions, and feeling the carotid pulse are not the initial actions to take when an infant is not breathing. The priority is to provide effective breaths to establish ventilation.

3. A 9-year-old child is brought to the clinic with a fever, rash, and swollen joints. The nurse notes that the child had a sore throat two weeks ago that was not treated. What condition should the nurse suspect?

• A. Scarlet fever
• B. Rheumatic fever
• C. Kawasaki disease
• D. Juvenile rheumatoid arthritis

Correct answer: B

Rationale: In this scenario, the child's symptoms of fever, rash, and swollen joints following an untreated sore throat two weeks ago are indicative of rheumatic fever. Rheumatic fever can develop as a complication of untreated streptococcal infections, leading to systemic inflammation and affecting various organs, including the joints. This condition manifests with symptoms such as fever, rash, and swollen joints, aligning with the child's presentation in this case. Scarlet fever typically presents with a sandpapery rash and strawberry tongue but does not involve joint inflammation. Kawasaki disease presents with fever, rash, and mucous membrane changes but does not typically involve joint swelling. Juvenile rheumatoid arthritis can cause joint swelling but is not directly linked to a recent untreated sore throat.

4. What action should the nurse implement when the infusion of chemotherapy via an implanted medication port is complete for a 16-year-old with acute myelocytic leukemia at the outpatient oncology clinic?

• A. Administer Zofran
• B. Obtain blood samples for RBCs, WBCs, and platelets
• C. Flush mediport with saline and heparin solution
• D. Initiate an infusion of normal saline

Correct answer: C

Rationale: The correct action for the nurse to implement when the chemotherapy infusion is complete is to flush the mediport with saline and heparin solution. This process helps prevent clotting and ensures the patency of the port, which is essential for future medication administrations and blood draws. Administering Zofran (Choice A) is not necessary after completing the chemotherapy infusion. Obtaining blood samples (Choice B) for RBCs, WBCs, and platelets is important but not the immediate action after completing the infusion. Initiating an infusion of normal saline (Choice D) is not required unless there is a specific indication for it.

5. Which nursing intervention is most important to include in the plan of care for a child with acute glomerulonephritis?

• A. Encourage fluid intake.
• B. Promote complete bed rest.
• C. Weigh the child daily.
• D. Administer vitamin supplements.

Correct answer: C

Rationale: Weighing the child daily is crucial in managing a child with acute glomerulonephritis as it helps in monitoring fluid retention, which is a key concern in this condition. Daily weight monitoring allows healthcare providers to assess changes in fluid status and adjust treatment accordingly. It is an essential component of the care plan to ensure the child's health status is closely monitored during the management of acute glomerulonephritis. Encouraging fluid intake (Choice A) is generally beneficial but may not be the priority in this case where fluid retention needs close monitoring. Promoting complete bed rest (Choice B) can be important but may not be the most critical intervention. Administering vitamin supplements (Choice D) may not directly address the immediate concerns related to fluid retention in acute glomerulonephritis.

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