Nursing Elites

1. What should the nurse include in the care plan for a 6-month-old infant admitted with a diagnosis of respiratory syncytial virus (RSV)?

• A. Provide small, frequent feedings
• B. Administer antibiotics
• C. Maintain strict isolation
• D. Elevate the head of the bed

Correct answer: D

Rationale: Elevating the head of the bed is crucial in the care plan for an infant with RSV as it helps improve breathing by facilitating better airflow and drainage of secretions. This position can also enhance comfort and reduce respiratory distress. Providing small, frequent feedings (Choice A) is generally beneficial for infants but is not specific to managing RSV. Administering antibiotics (Choice B) is not indicated for RSV as it is caused by a virus, and antibiotics are ineffective against viral infections. Maintaining strict isolation (Choice C) is important to prevent the spread of contagious infections but is not a direct intervention for improving the infant's respiratory status in RSV.

2. Seizures in children most often result from

• A. an abrupt rise in body temperature
• B. an inflammatory process in the brain
• C. a temperature greater than 102°F
• D. a life-threatening infection

Correct answer: A

Rationale: Seizures in children most often result from an abrupt rise in body temperature, leading to febrile seizures. Febrile seizures are common in young children and are typically triggered by a rapid increase in body temperature, often due to infections or other causes. An inflammatory process in the brain (Choice B) is less common as a cause of seizures in children and is usually associated with specific conditions like encephalitis or meningitis. While a temperature greater than 102°F (Choice C) may trigger a febrile seizure, it is the abrupt rise in temperature that is the primary cause. Choice D, a life-threatening infection, is a broad and less specific cause compared to the direct trigger of an abrupt rise in body temperature.

3. A child is brought to the clinic after tripping over a rock. The child states, 'I twisted my ankle,' and is given a diagnosis of a sprain. What intervention is most important for the nurse to include in the discharge instructions for this child?

• A. For the first 24 hours, apply ice for 20 minutes and then remove for 60 minutes.
• B. Bed rest with the leg elevated for 36 hours.
• C. May take an NSAID for pain as needed.
• D. Use a compression dressing for 72 hours.

Correct answer: A

Rationale: The correct intervention for a sprained ankle is to apply ice for 20 minutes every hour for the first 24 hours, then remove for 60 minutes to prevent tissue damage. This regimen helps reduce swelling and pain. Bed rest with the leg elevated for an extended period (36 hours) may lead to stiffness and decreased range of motion. While NSAIDs can be used for pain, they may not be necessary if pain is manageable with ice and rest. Using a compression dressing for 72 hours continuously may impede proper circulation and delay healing by restricting blood flow.

4. When caring for a neonate with a suspected tracheoesophageal fistula, what nursing care should be included?

• A. Elevating the head but giving nothing by mouth
• B. Elevating the head for feedings
• C. Feeding glucose water only
• D. Avoiding suctioning unless the infant is cyanotic

Correct answer: A

Rationale: In a neonate with a suspected tracheoesophageal fistula, elevating the head but giving nothing by mouth is crucial to prevent aspiration. Placing the neonate in a semi-upright position helps reduce the risk of reflux and aspiration of gastric contents into the lungs. Elevating the head for feedings (Choice B) would still pose a risk of aspiration as the neonate may aspirate during feeding. Feeding glucose water only (Choice C) is not appropriate and does not address the risk of aspiration associated with a tracheoesophageal fistula. Avoiding suctioning unless the infant is cyanotic (Choice D) is incorrect because suctioning may be necessary for maintaining airway patency, regardless of cyanosis, in a neonate with a suspected tracheoesophageal fistula.

5. What are the most common signs and symptoms of leukemia related to bone marrow involvement?

• A. petechiae, infection, fatigue
• B. headache, papilledema, irritability
• C. muscle wasting, weight loss, fatigue
• D. decreased intracranial pressure, psychosis, confusion

Correct answer: A

Rationale: The correct answer is A: petechiae, infection, fatigue. In leukemia, bone marrow involvement leads to a decrease in normal blood cell production, resulting in petechiae (small red or purple spots on the skin), increased susceptibility to infections due to decreased white blood cells, and fatigue from anemia. Choices B, C, and D are incorrect because they do not directly relate to the typical signs and symptoms of leukemia with bone marrow involvement. Headache, papilledema, irritability, muscle wasting, weight loss, decreased intracranial pressure, psychosis, and confusion are not typically associated with leukemia and bone marrow involvement.

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