Nursing Elites

1. What behavior is essential for preventing in a child postoperatively after undergoing heart surgery to repair defects associated with tetralogy of Fallot?

• A. Crying
• B. Coughing
• C. Straining at stool
• D. Unnecessary movement

Correct answer: C

Rationale: Preventing straining at stool is crucial postoperatively after heart surgery for tetralogy of Fallot to avoid increasing intrathoracic pressure and placing stress on the surgical site. This can help prevent complications and promote faster healing. While crying, coughing, and unnecessary movement are common postoperative behaviors, they are not specifically linked to worsening outcomes in this context. Straining at stool is particularly emphasized due to its potential to impact the surgical site and overall recovery process.

2. A nurse is teaching the parents of a child with a diagnosis of type 1 diabetes mellitus about blood glucose monitoring. What should the nurse emphasize?

• A. Checking blood glucose levels before meals and at bedtime
• B. Using a lancet device to obtain blood samples
• C. Using urine test strips for monitoring
• D. Recognizing signs of hypoglycemia

Correct answer: A

Rationale: Checking blood glucose levels before meals and at bedtime is essential for managing type 1 diabetes mellitus. This timing helps in assessing the effectiveness of insulin therapy, making adjustments to insulin doses, and preventing hyperglycemia and hypoglycemia. Option B is incorrect because it focuses on the method of obtaining blood samples rather than the timing of monitoring. Option C is incorrect as urine test strips are not recommended for accurate blood glucose monitoring in type 1 diabetes. Option D, recognizing signs of hypoglycemia, is important but not the primary emphasis when teaching about blood glucose monitoring.

3. A child is admitted with extensive burns. The nurse notes burns on the child’s lips and singed nasal hairs. The nurse should suspect that the child has a(n)

• A. chemical burn
• B. inhalation injury
• C. electrical burn
• D. hot-water scald

Correct answer: B

Rationale: Burns on the lips and singed nasal hairs are indicative of an inhalation injury. This suggests that the child has likely inhaled hot gases or smoke, leading to damage in the respiratory tract. Choice A, chemical burn, is incorrect because the symptoms described are more aligned with inhalation rather than direct contact with chemicals. Choice C, electrical burn, is incorrect as there are no mentions of contact with an electrical source. Choice D, hot-water scald, is also incorrect as the presentation of burns on the lips and singed nasal hairs is not characteristic of scald injuries.

4. 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: The correct answer is B: Assess for a patent airway. When dealing with a child who has sustained partial thickness burns, the priority is ensuring a patent airway due to the risk of respiratory compromise. Checking the child's skin color (choice A) may be important but is secondary to assessing the airway. While observing for symmetric breathing (choice C) is crucial, assessing the airway takes precedence in this situation. Palpating the child's pulse (choice D) is not the initial priority when managing burns and potential airway compromise.

5. A child with a diagnosis of appendicitis is scheduled for surgery. What preoperative intervention is important for the nurse to perform?

• A. Administering antibiotics
• B. Maintaining strict NPO status
• C. Encouraging fluid intake
• D. Monitoring for signs of infection

Correct answer: B

Rationale: The correct preoperative intervention for a child with appendicitis scheduled for surgery is maintaining strict NPO (nothing by mouth) status. This is crucial to reduce the risk of aspiration during anesthesia induction and prevent potential complications during surgery. Administering antibiotics may be a part of the treatment plan but is not a preoperative intervention. Encouraging fluid intake is contraindicated preoperatively to avoid delays in surgery and complications related to anesthesia. Monitoring for signs of infection is important postoperatively to assess for any complications that may arise due to the surgical procedure.

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