Nursing Elites

1. A child sitting on a chair in a playroom starts to have a tonic-clonic seizure with a clenched jaw. What is the nurse’s best initial action?

• A. Attempt to open the jaw.
• B. Place the child on the floor.
• C. Call out for assistance from staff.
• D. Place a pillow under the child’s head.

Correct answer: B

Rationale: The best initial action during a tonic-clonic seizure is to place the child on the floor. This action helps prevent injury by providing a safe environment and allows for better management of the seizure episode. Attempting to open the jaw is not recommended as it may cause harm to the child or the nurse. Calling out for assistance is important but should not delay ensuring the child's safety first. Placing a pillow under the child's head is not advisable during a seizure as it can pose a risk of suffocation or choking.

2. The nurse is providing care to a child with a long-leg hip spica cast. What is the priority nursing diagnosis?

• A. Risk for impaired skin integrity due to the cast and its location.
• B. Deficient knowledge related to cast care.
• C. Risk for delayed development related to immobility.
• D. Self-care deficit related to immobility.

Correct answer: A

Rationale: The correct answer is A: Risk for impaired skin integrity due to the cast and its location. When a child has a long-leg hip spica cast, the priority nursing diagnosis is to prevent impaired skin integrity. This is because the child's mobility is restricted, and pressure from the cast can lead to skin breakdown. Option B is incorrect as while education is essential, it is not the priority when skin integrity is at risk. Option C is incorrect because while immobility can impact development, immediate skin integrity concerns take precedence. Option D is incorrect as self-care deficit, while important, is secondary to preventing skin breakdown in this scenario.

3. The healthcare provider notes that a child has lost 8 pounds after 4 days of hospitalization for acute glomerulonephritis. This is most likely the result of

• A. poor appetite
• B. increased potassium intake
• C. reduction of edema
• D. restriction to bed rest

Correct answer: C

Rationale: In acute glomerulonephritis, weight loss is most likely due to the reduction of edema. Edema is a common symptom of glomerulonephritis, which causes fluid retention and swelling in the body. As treatment progresses and the condition improves, the reduction of edema leads to weight loss. Choices A, B, and D are incorrect as they do not directly address the underlying pathophysiology of acute glomerulonephritis and its impact on weight loss.

4. A 3-month-old infant has been hospitalized with respiratory syncytial virus (RSV). What is the priority intervention?

• A. Administering an antiviral agent
• B. Clustering care to conserve energy
• C. Offering oral fluids to promote hydration
• D. Providing an antitussive agent when necessary

Correct answer: B

Rationale: The priority intervention for a 3-month-old infant hospitalized with respiratory syncytial virus (RSV) is to cluster care to conserve energy. Infants with RSV often have difficulty breathing and need to rest frequently. Clustering care involves grouping nursing interventions to allow for longer periods of rest between activities, which helps prevent exhaustion and conserve the infant's energy. Administering an antiviral agent is not the primary intervention for RSV, as it is a viral infection and antiviral agents are not typically used for RSV. Offering oral fluids is important for hydration but may not be the priority when the infant is struggling to breathe. Providing an antitussive agent should be done judiciously and under medical guidance, as suppressing the cough reflex can be detrimental in RSV cases where coughing helps clear airway secretions.

5. When caring for a child diagnosed with bronchiolitis, what is the priority nursing intervention?

• A. Administering bronchodilators
• B. Providing respiratory therapy
• C. Monitoring oxygen saturation
• D. Encouraging fluid intake

Correct answer: B

Rationale: The priority nursing intervention for a child with bronchiolitis is providing respiratory therapy. This intervention aims to maintain airway patency, optimize oxygenation, and support effective breathing. Administering bronchodilators, though important, may not be the initial priority as respiratory therapy takes precedence in ensuring adequate oxygenation and ventilation. Monitoring oxygen saturation is crucial but is usually part of the ongoing assessment following the initiation of respiratory therapy. Encouraging fluid intake is essential for hydration but is not the priority intervention when addressing the respiratory distress associated with bronchiolitis.

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