Nursing Elites

1. A male infant with bronchiolitis is brought to the clinic by his mother. The infant is congested and febrile with a capillary refill of 2 seconds. Which information should the nurse discuss with the mother?

• A. Encourage the infant to play
• B. Limit the amount of oral intake
• C. Keep the infant isolated from others
• D. Place the infant on their back for naps

Correct answer: C

Rationale: Bronchiolitis is a highly contagious respiratory infection commonly caused by viruses. Isolating the infant from others is crucial to prevent the spread of the infection to other vulnerable individuals, especially those with weakened immune systems. Encouraging play may not be appropriate as the infant is sick and needs rest. Limiting oral intake might be necessary if the infant is having difficulty swallowing due to respiratory distress. Placing the infant on their back for naps is a safe sleep practice but not the priority in this situation where preventing transmission of the infection is crucial.

2. An adolescent female who is leaning forward with her hands on her knees to breathe tells the practical nurse that she has been using triamcinolone (Azmacort) inhalation aerosol before coming to the clinic. Which action should the PN implement?

• A. Obtain vital signs and assess breath sounds for wheezing.
• B. Collect a blood sample for white blood cell count.
• C. Give the client a nebulizer breathing treatment.
• D. Administer another dose of Azmacort.

Correct answer: A

Rationale: When a patient presents with breathing difficulties, the first action should be to assess vital signs and breath sounds to evaluate the severity of the condition. This assessment will provide crucial information to determine the appropriate course of action and treatment. Collecting a blood sample for a white blood cell count, giving a nebulizer treatment, or administering another dose of Azmacort would not be the initial priority in this situation. Therefore, option A is the correct choice as it focuses on assessing the patient's respiratory status to guide further interventions.

3. The practical nurse (PN) is caring for an adolescent who has been diagnosed with mononucleosis. Which activity should the PN advise the adolescent to avoid?

• A. Playing video games.
• B. Drinking caffeinated beverages.
• C. Participating in contact sports.
• D. Eating spicy foods.

Correct answer: C

Rationale: Contact sports should be avoided in mononucleosis due to the risk of spleen rupture, which is a serious complication of the disease. The spleen can enlarge in mononucleosis, making it more susceptible to injury from contact sports, potentially leading to a life-threatening situation if rupture occurs.

4. While teaching a parenting class to new parents, the nurse describes the needs of infants and toddlers regarding discipline and limit setting. What is the most important reason for implementing such parenting behaviors?

• A. Children need help in developing social skills.
• B. This age group fears loss of self-control.
• C. They provide the child with a sense of security.
• D. Children must learn to deal with authority.

Correct answer: C

Rationale: Implementing discipline and limit setting for infants and toddlers is primarily important as it provides them with a sense of security. This sense of security is crucial for their emotional and psychological development, helping them feel safe and supported as they explore the world around them. Choice A is incorrect because while developing social skills is important, the primary reason for discipline and limit setting in this context is to provide security. Choice B is incorrect as it does not address the main reason for implementing discipline and limit setting. Choice D is incorrect as the primary focus is not about dealing with authority at this early stage of development.

5. A 13-year-old client with type 1 diabetes presents to the clinic with a blood glucose level of 400 mg/dL. The client reports feeling thirsty and having frequent urination. What is the nurse’s priority action?

• A. Administer insulin as prescribed
• B. Encourage the client to drink water
• C. Check the client’s urine for ketones
• D. Reinforce the importance of diet and exercise

Correct answer: A

Rationale: In a client with type 1 diabetes presenting with hyperglycemia (blood glucose level of 400 mg/dL) and symptoms of thirst and frequent urination, the priority action for the nurse is to administer insulin as prescribed. Insulin helps lower the blood glucose level and prevents complications like diabetic ketoacidosis. While encouraging hydration is essential, administering insulin is crucial to address the high blood glucose levels. Checking urine for ketones is important in diabetic management but is secondary to administering insulin in this scenario. Reinforcing diet and exercise importance is vital for diabetes management but not the priority in acute hyperglycemia.

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