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. The practical nurse is reinforcing information about Lyme disease prevention with a client who is preparing for a camping trip with family. Which statement by the client informs the nurse that the client understands the instruction?

• A. I'll make sure my son wears dark clothing on his hike.
• B. I'll get a prescription for amoxicillin to take with us.
• C. We should all get the Lyme disease vaccine before our trip.
• D. We will wear long pants and long-sleeved shirts in the woods.

Correct answer: D

Rationale: The correct answer is D. Wearing long pants and long-sleeved shirts is an effective preventive measure against tick bites, which reduces the risk of contracting Lyme disease. This attire helps to minimize skin exposure to ticks, thereby decreasing the chances of a tick attaching and transmitting the disease-causing bacteria.

3. The healthcare provider is caring for a 6-year-old child diagnosed with glomerulonephritis. Which finding should the healthcare provider report promptly to the healthcare provider?

• A. Dark-colored urine
• B. Mild periorbital edema
• C. Blood pressure of 150/95 mm Hg
• D. Urine output of 250 mL in 24 hours

Correct answer: C

Rationale: Hypertension is a serious complication of glomerulonephritis, as it can lead to further renal damage. A blood pressure reading of 150/95 mm Hg is elevated and should be reported promptly to the healthcare provider for immediate management to prevent complications. Dark-colored urine can be a common symptom of glomerulonephritis due to blood in the urine but is not as urgent as managing hypertension. Mild periorbital edema can also be seen in glomerulonephritis but is not as concerning as elevated blood pressure. Urine output of 250 mL in 24 hours indicates oliguria, which is a concern, but addressing hypertension takes priority to prevent further renal damage.

4. A 5-year-old child is brought to the emergency department with severe abdominal pain and vomiting. The child’s parent reports that the pain started suddenly and is located in the lower right abdomen. What should the nurse do first?

• A. Administer pain medication
• B. Notify the healthcare provider immediately
• C. Start an IV line for fluid administration
• D. Obtain a complete blood count

Correct answer: B

Rationale: The correct answer is to notify the healthcare provider immediately. The child's presentation of sudden, severe abdominal pain in the lower right abdomen is highly concerning for appendicitis, a medical emergency. Promptly notifying the healthcare provider is crucial for further evaluation and management. Administering pain medication as the first action might mask symptoms and delay diagnosis. Starting an IV line for fluid administration and obtaining a complete blood count are important interventions but should come after healthcare provider notification.

5. When assessing the breath sounds of an 18-month-old child who is crying, what action should the healthcare professional take?

• A. Document that the assessment is not available because the child is crying.
• B. Ask the caregiver to quiet the child so breath sounds can be auscultated.
• C. Allow the child to play with a stethoscope to distract them during auscultation.
• D. Auscultate and document breath sounds, noting that the child was crying at the time.

Correct answer: C

Rationale: Allowing the child to play with a stethoscope can help distract them, making it easier to auscultate breath sounds. This approach can create a more cooperative and engaging environment for the child, facilitating a more accurate assessment of their breath sounds. Choice A is incorrect because it does not address the need for an assessment. Choice B is not ideal as it puts pressure on the caregiver and may not be effective in calming the child. Choice D is not the best option as it does not actively involve the child in the assessment process and may not provide an accurate representation of their breath sounds.

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