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. An infant with a congenital heart defect is being given gavage feedings. The parents ask the nurse why this is necessary. How should the nurse respond?

• A. It limits the chance of vomiting.
• B. It allows the feeding to be administered rapidly.
• C. The energy that would have been expended on sucking is conserved.
• D. The quantity of nutritional liquid can be regulated better than with a bottle.

Correct answer: C

Rationale: The correct answer is C: 'The energy that would have been expended on sucking is conserved.' Gavage feedings are necessary for infants with congenital heart defects as they help conserve the infant’s energy by eliminating the need for sucking, which can be taxing for infants with cardiac issues. Choice A is incorrect because gavage feedings are not primarily used to limit vomiting. Choice B is incorrect as the speed of administration is not the main reason for gavage feedings in this case. Choice D is incorrect because the regulation of the quantity of nutritional liquid is not the primary rationale for gavage feedings in infants with congenital heart defects.

3. An order is written for an isotonic enema for a 2-year-old child. What is the maximum amount of fluid the nurse should administer without a specific order from the health care provider?

• A. 100 to 150 mL
• B. 155 to 250 mL
• C. 255 to 360 mL
• D. 365 to 500 mL

Correct answer: B

Rationale: For a 2-year-old child, the maximum recommended amount of fluid for an isotonic enema is between 155 to 250 mL to prevent overdistension and potential harm. Choice A (100 to 150 mL) is too low and may not be effective in achieving the desired outcome. Choices C (255 to 360 mL) and D (365 to 500 mL) exceed the safe range for a 2-year-old child and can lead to overdistension, electrolyte imbalance, or other complications. Therefore, the correct answer is B.

4. What is an early sign of congestive heart failure that the nurse should recognize?

• A. Tachypnea
• B. Bradycardia
• C. Inability to sweat
• D. Increased urinary output

Correct answer: A

Rationale: Tachypnea, which refers to rapid breathing, is an early sign of congestive heart failure. In heart failure, the heart's inability to pump efficiently can lead to fluid accumulation in the lungs, causing the child to breathe faster to try to compensate for the decreased oxygen exchange. Bradycardia (slow heart rate) is not typically associated with congestive heart failure; instead, it may indicate a different issue. Inability to sweat is not a common early sign of congestive heart failure. Increased urinary output is not a typical early sign of congestive heart failure; instead, it may be a sign of other conditions like diabetes or kidney issues.

5. During a primary survey of a child with partial thickness burns over the upper body areas, what action should the nurse take first?

• A. Inspect the child's skin color.
• B. Assess for a patent airway.
• C. Observe for symmetric breathing.
• D. Palpate the child's pulse.

Correct answer: B

Rationale: When managing a child with partial thickness burns over the upper body areas, the priority action during the primary survey is to assess for a patent airway. This step is crucial as burns in this region can lead to airway compromise, potentially causing rapid deterioration in the child's condition. Checking for a patent airway ensures that the child can breathe adequately, which is essential for oxygenation and ventilation. Inspecting the child's skin color (Choice A) is an important assessment but should follow ensuring a patent airway. Observing for symmetric breathing (Choice C) is relevant, but the immediate focus should be on securing the airway. Palpating the child's pulse (Choice D) is also a vital assessment, but in this scenario, the priority is to assess and maintain a clear airway to support respiratory function and oxygen delivery.

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