Nursing Elites

1. A female child, age 2, is brought to the emergency department after ingesting an unknown number of aspirin tablets about 30 minutes earlier. Her father is blaming the mother for neglecting the child while she was cooking. On entering the examination room, the child is crying and clinging to the mother. Which data should the nurse obtain first?

• A. Heart rate, respiratory rate, and blood pressure
• B. Recent exposure to communicable diseases
• C. Number of immunizations received
• D. Height and weight

Correct answer: A

Rationale: In this scenario, the priority is to assess the child's vital signs first, including heart rate, respiratory rate, and blood pressure. These data will provide critical information on the child's current physiological status and guide further interventions. Option B, recent exposure to communicable diseases, is not the priority in an acute ingestion situation. Option C, number of immunizations received, and option D, height and weight, are important but not as critical as assessing vital signs in this immediate situation.

2. The healthcare provider is assessing a newborn who is 2 hours old. Which finding requires immediate intervention?

• A. Acrocyanosis
• B. Respiratory rate of 60 breaths per minute
• C. Grunting with nasal flaring
• D. Heart rate of 140 beats per minute

Correct answer: C

Rationale: Grunting with nasal flaring is a concerning sign of respiratory distress in a newborn that can indicate inadequate oxygenation. This finding requires immediate intervention to ensure the newborn's respiratory status is stabilized and to prevent further complications. Prompt assessment and appropriate intervention are crucial in such cases to prevent respiratory compromise and potential deterioration. Acrocyanosis, which is bluish discoloration of the extremities, is a common finding in newborns and usually resolves on its own. A respiratory rate of 60 breaths per minute and a heart rate of 140 beats per minute are within normal ranges for a newborn and do not indicate immediate intervention is needed.

3. Mrs. Byers tells the nurse that she is very worried because her 2-year-old child does not finish his meals. What should the nurse advise the mother?

• A. Make the child seat with the family in the dining room until he finishes his meal
• B. Provide quiet environment for the child before meals
• C. Do not give snacks to the child before meals
• D. Put the child on a chair and feed him

Correct answer: C

Rationale: Providing a quiet environment can help the child focus on eating.

4. In the treatment of an infected hematoma, which of the following is NOT recommended?

• A. Incision and drainage
• B. Systemic antibiotics
• C. A and B
• D. Vitamin E

Correct answer: D

Rationale: Vitamin E is not a standard treatment for infected hematomas. The primary interventions for infected hematomas typically involve incision and drainage to remove infected fluid and debris, along with the administration of systemic antibiotics to combat the infection. Vitamin E does not play a significant role in the treatment of infected hematomas and is therefore not recommended as a primary treatment option. Choice A (Incision and drainage) and Choice B (Systemic antibiotics) are recommended treatments for infected hematomas as they help in removing infected fluid and combating the infection, respectively. Therefore, the correct answer is D, Vitamin E.

5. Non-pharmacological techniques can help lower blood pressure. Which of the following is not considered one of these types of techniques?

• A. Dietary changes
• B. Multivitamins
• C. Smoking cessation
• D. Limiting caffeine

Correct answer: B

Rationale: Multivitamins are not typically considered a non-pharmacological technique for lowering blood pressure. While dietary changes, smoking cessation, and limiting caffeine intake can positively impact blood pressure levels, multivitamins are generally not specifically recommended as a primary intervention for this purpose. Dietary changes can include reducing salt intake and increasing potassium-rich foods, which are known to help manage blood pressure. Smoking cessation is crucial due to the negative impact of smoking on blood pressure and overall cardiovascular health. Limiting caffeine intake is advised as excessive caffeine consumption can lead to a temporary increase in blood pressure. Therefore, focusing on lifestyle modifications like healthy eating, smoking cessation, and caffeine reduction is more effective in managing blood pressure than relying on multivitamins.

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