Nursing Elites

1. A 7-year-old has been diagnosed with cystic fibrosis. Chest physiotherapy has been ordered. What information should the nurse give to the parents regarding when chest physiotherapy is done?

• A. Before aerosol treatment
• B. After suctioning
• C. Before postural drainage
• D. Before meals

Correct answer: D

Rationale: The correct answer is D: 'Before meals'. Chest physiotherapy should be performed before meals to reduce the risk of vomiting and to ensure that the airways are clear for effective nutrition. Choices A, B, and C are incorrect because chest physiotherapy is ideally done before meals to optimize its benefits and avoid complications associated with timing.

2. What is a common sign of moderate dehydration in children?

• A. Dry mucous membranes
• B. Normal capillary refill
• C. Hyperactive bowel sounds
• D. Edema

Correct answer: A

Rationale: Dry mucous membranes are a common sign of moderate dehydration in children, indicating a loss of bodily fluids. When a child is moderately dehydrated, the mucous membranes in the mouth and nose may appear dry. This condition can occur due to various factors such as vomiting, diarrhea, or inadequate fluid intake. Normal capillary refill (choice B) is not typically associated with dehydration; it is a measure of circulatory status. Hyperactive bowel sounds (choice C) can be present in conditions like gastroenteritis but are not specific to dehydration. Edema (choice D) is the retention of fluid in the body and is not a typical sign of dehydration.

3. Where is the best place to observe for the presence of petechiae in dark-skinned individuals?

• A. Face
• B. Buttocks
• C. Oral mucosa
• D. Palms and soles

Correct answer: C

Rationale: The oral mucosa and conjunctivae are the best places to observe petechiae in dark-skinned individuals because these areas have less pigmentation.

4. The nurse is discussing toddler development with a parent. Which intervention will foster the achievement of autonomy?

• A. Help the toddler complete tasks
• B. Encourage the toddler to do things for themselves when capable
• C. Provide opportunities for the toddler to play with other children
• D. Help the toddler learn the difference between right and wrong

Correct answer: B

Rationale: Encouraging the toddler to do things for themselves when capable is the correct intervention to foster autonomy. This approach helps the toddler develop independence, self-confidence, and a sense of achievement. Choice A is incorrect as it focuses on assisting rather than encouraging independence. Choice C is incorrect as playing with other children primarily fosters social skills, not necessarily autonomy. Choice D is incorrect as learning the difference between right and wrong is related to moral development, not autonomy.

5. The nurse is assessing a 3-day-old breastfed newborn who weighed 3400 g (7 pounds, 8 oz) at birth. The infant’s mother is now concerned because the infant weighs 3147 g (6 pounds, 15 oz). The most appropriate nursing intervention is what?

• A. Recommend supplemental feedings of formula.
• B. Explain that this weight loss is within normal limits.
• C. Assess the child further to determine the cause of excessive weight loss.
• D. Encourage the mother to express breast milk for bottle-feeding the infant.

Correct answer: B

Rationale: A neonate normally loses about 10% of the birth weight by age 3 to 4 days. The birth weight is usually regained by the 10th day of life. In this case, the weight loss from 3400 g to 3147 g is within the expected range. Therefore, the most appropriate action is to explain to the mother that this weight loss is within normal limits. Choice A is incorrect because supplemental feedings of formula are not indicated for this expected weight loss in a breastfed newborn. Choice C is incorrect as there is no evidence to suggest excessive weight loss at this point. Choice D is unnecessary at this stage and may not align with the current situation of normal weight loss post-birth.

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