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. 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.

3. A nurse on the pediatric unit is observing the developmental skills of several 2-year-old children in the playroom. Which child should the nurse continue to evaluate?

• A. Cannot stand on one foot
• B. Builds a tower of 7 blocks
• C. Uses echolalia when speaking
• D. Colors outside the lines of a picture

Correct answer: C

Rationale: The correct answer is C because using echolalia (repeating words or phrases) is not typical for a 2-year-old and may indicate the need for further evaluation. Choices A, B, and D are within the expected developmental skills for a 2-year-old. While a 2-year-old may not be able to stand on one foot for an extended period, it is not a concerning developmental milestone at this age. Building a tower of 7 blocks and coloring outside the lines of a picture are both age-appropriate activities that demonstrate fine motor skills and creativity, respectively. However, echolalia at this age could be a sign of an underlying communication or developmental issue that warrants further assessment and monitoring.

4. A child with a diagnosis of congenital heart disease is admitted to the hospital. What should the nurse include in the child’s care plan?

• A. Monitoring fluid status
• B. Encouraging activity
• C. Promoting a high-calorie diet
• D. Maintaining oxygen therapy

Correct answer: A

Rationale: Monitoring fluid status is crucial for a child with congenital heart disease because these children are at risk of fluid overload which can worsen their condition. Monitoring fluid intake and output helps prevent complications like congestive heart failure. Encouraging activity (Choice B) should be individualized based on the child's condition and tolerance, as excessive activity can strain the heart. Promoting a high-calorie diet (Choice C) is not typically recommended for children with congenital heart disease unless specifically indicated, as excessive weight gain can worsen their cardiac function. Maintaining oxygen therapy (Choice D) may be necessary in some cases, but monitoring fluid status is a more fundamental aspect of care for children with congenital heart disease.

5. A healthcare professional is assessing a child with suspected bacterial meningitis. What is a common clinical manifestation that the healthcare professional is likely to observe?

• A. Rash
• B. Photophobia
• C. Jaundice
• D. Kernig sign

Correct answer: D

Rationale: A common clinical manifestation of bacterial meningitis is a positive Kernig sign, indicating irritation of the meninges. Rash (Choice A) is not typically associated with bacterial meningitis. Photophobia (Choice B) can be present but is more commonly seen in viral meningitis. Jaundice (Choice C) is not a typical clinical manifestation of meningitis and is more indicative of liver dysfunction.

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