Nursing Elites

1. A home care nurse is visiting a family for the first time. The 4-week-old infant had surgery for exstrophy of the bladder and creation of an ileal conduit soon after birth. When the nurse arrives, the mother appears tired, and the baby is crying. After an introduction, which is the most appropriate statement by the nurse?

• A. “Tell me about your daily routine.”
• B. “You look tired. Is everything alright?”
• C. “When was the last time the baby had a bottle?”
• D. “Oh, it looks like you two are having a bad day.”

Correct answer: A

Rationale: Asking about the daily routine is the most appropriate statement by the nurse in this scenario. It allows the nurse to gather important information about the family's schedule, feeding patterns, and overall care routine for the infant. This open-ended question helps the nurse assess the family's situation comprehensively and identify any areas where support may be needed. Choices B, C, and D are less appropriate as they do not focus on gathering relevant information about the family's routine and needs but rather make assumptions or ask about specific isolated events.

2. You are managing a 10-month-old infant who has had severe diarrhea and vomiting for 3 days and is now showing signs of shock. You have initiated supplemental oxygen therapy and elevated the lower extremities. En route to the hospital, you note that the child's work of breathing has increased. What must you do first?

• A. Lower the extremities and reassess the child
• B. Begin positive pressure ventilations and reassess the child
• C. Place a nasopharyngeal airway and increase the oxygen flow
• D. Listen to the lungs with a stethoscope for abnormal breath sounds

Correct answer: A

Rationale: In this scenario, the infant is presenting with signs of respiratory distress, as evidenced by the increased work of breathing. Lowering the extremities can help reduce the workload on the diaphragm and improve respiratory mechanics. This action can be beneficial in optimizing the infant's breathing before considering more invasive interventions. Option B, initiating positive pressure ventilations, should be considered if the infant's condition deteriorates further and not as the first step. Option C, placing a nasopharyngeal airway and increasing oxygen flow, is not indicated as the primary intervention for increased work of breathing. Option D, listening to the lungs with a stethoscope, may provide additional information but is not the most urgent action needed in this situation.

3. A 6-month-old infant is diagnosed with cystic fibrosis. What explanation should the nurse provide to the parents about this condition?

• A. It is a condition affecting the respiratory and digestive systems.
• B. It is an autoimmune disorder affecting multiple organs.
• C. It is a genetic disorder that can be managed with medication.
• D. It is a condition caused by prenatal exposure to toxins.

Correct answer: A

Rationale: The correct answer is A: 'It is a condition affecting the respiratory and digestive systems.' Cystic fibrosis is a genetic disorder that primarily affects the respiratory and digestive systems. It is caused by a defective gene that leads to the production of thick and sticky mucus in these organs. This mucus can clog airways in the lungs and block the ducts in the pancreas, affecting digestion. Choice B is incorrect because cystic fibrosis is not an autoimmune disorder; it is a genetic condition. Choice C is partially correct in that cystic fibrosis is a genetic disorder, but merely managing it with medication oversimplifies the comprehensive care needed for individuals with cystic fibrosis. Choice D is incorrect as cystic fibrosis is not caused by prenatal exposure to toxins but is a genetic condition inherited from parents.

4. What is an important nursing responsibility when a dysrhythmia is suspected?

• A. Order an immediate electrocardiogram
• B. Count the radial pulse every minute for five times
• C. Count the apical pulse for 1 full minute and compare the rate with the radial pulse rate
• D. Have someone else take the radial pulse simultaneously with the apical pulse

Correct answer: C

Rationale: When a dysrhythmia is suspected, it is important for nurses to count the apical pulse for a full minute and compare it with the radial pulse rate. This method helps in identifying dysrhythmias because discrepancies between the apical and radial pulse rates can indicate irregular heart rhythms. Option A is incorrect because ordering an immediate electrocardiogram may not always be feasible or necessary as a first step. Option B, counting the radial pulse multiple times, is less accurate than comparing the apical and radial pulse rates. Option D involves an unnecessary step of having another person take simultaneous pulses when the nurse can do it effectively alone.

5. A 5-year-old child is diagnosed with acute glomerulonephritis. What is a key assessment the nurse should perform?

• A. Monitor blood glucose levels
• B. Monitor respiratory rate
• C. Monitor urine output
• D. Monitor for signs of infection

Correct answer: C

Rationale: In a child diagnosed with acute glomerulonephritis, monitoring urine output is a crucial assessment. Acute glomerulonephritis affects the kidneys, leading to decreased urine output due to impaired kidney function. Monitoring urine output helps assess renal perfusion, fluid status, and kidney function. This assessment is essential in determining the effectiveness of treatment and identifying complications. Monitoring blood glucose levels (Choice A) is not directly related to acute glomerulonephritis. Respiratory rate (Choice B) may be important in other conditions but is not a key assessment for acute glomerulonephritis. Monitoring for signs of infection (Choice D) is important in general, but it is not specific to the primary issue of impaired kidney function in acute glomerulonephritis.

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