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. Which developmental behavior should the practical nurse identify as normal for a 6-month-old infant?

• A. Rolls over completely.
• B. Creeps on all fours.
• C. Pulls self to a standing position.
• D. Assumes a sitting position independently.

Correct answer: A

Rationale: The correct answer is A: 'Rolls over completely.' By 6 months of age, infants typically achieve the milestone of rolling over completely. This ability demonstrates increasing strength and coordination. Creeping on all fours, pulling self to a standing position, and assuming a sitting position independently are skills that are usually developed at later stages of infancy. Creeping usually occurs around 9-10 months, pulling self to a standing position around 9-12 months, and assuming a sitting position independently around 8 months. Therefore, at 6 months, rolling over completely is the most expected developmental behavior.

3. A 2-week-old female infant is hospitalized for the surgical repair of an umbilical hernia. After returning to the postoperative neonatal unit, her RR and HR have increased during the last hour. Which intervention should the nurse implement?

• A. Notify the healthcare provider of these findings
• B. Administer a PRN analgesic as prescribed
• C. Document the findings in the infant's medical record
• D. Comfort the infant by swaddling and gently rocking

Correct answer: A

Rationale: In a postoperative neonatal setting, an increase in respiratory rate (RR) and heart rate (HR) in an infant could indicate pain or distress. It is crucial for the nurse to notify the healthcare provider promptly to assess the infant's condition and provide appropriate interventions. Prompt communication with the healthcare provider ensures timely evaluation and management of the infant's discomfort or distress, promoting optimal postoperative recovery and comfort. Administering analgesics without healthcare provider assessment could mask underlying issues, documenting findings alone does not address the immediate need for intervention, and comforting may not resolve the underlying cause of increased RR and HR.

4. The caregiver is caring for a 10-year-old child with a history of frequent ear infections. The parents are concerned about their child’s hearing and speech development. What is the caregiver’s best response?

• A. Let’s schedule a hearing test and refer to a speech therapist if needed
• B. Most children outgrow ear infections and speech delays
• C. There is no need to worry unless the infections persist into adolescence
• D. Your child’s hearing and speech should be normal by now

Correct answer: A

Rationale: The appropriate response for the caregiver is to address the parents' concerns by suggesting scheduling a hearing test and potentially referring the child to a speech therapist if necessary. This proactive approach can help evaluate and support the child's hearing and speech development effectively. Choice B is incorrect as assuming that most children outgrow ear infections and speech delays may overlook potential issues that need intervention. Choice C is wrong because waiting until adolescence to address concerns may lead to missed opportunities for early intervention. Choice D is incorrect as it dismisses the parents' valid concerns without offering a solution or further evaluation.

5. A child who is admitted to the hospital with anemia is anxious, fearful, and hyperventilating. The nurse anticipates the child developing which acid-base imbalance?

• A. Metabolic acidosis
• B. Respiratory acidosis
• C. Respiratory alkalosis
• D. Metabolic alkalosis

Correct answer: C

Rationale: In this scenario, the child is hyperventilating, which leads to excessive loss of carbon dioxide. This loss of carbon dioxide causes respiratory alkalosis due to a decrease in the partial pressure of carbon dioxide in the blood. Therefore, the correct answer is respiratory alkalosis. Choices A, B, and D are incorrect. Metabolic acidosis is characterized by a decrease in pH and bicarbonate levels due to conditions like kidney disease. Respiratory acidosis is caused by retention of carbon dioxide, leading to an increase in the partial pressure of carbon dioxide. Metabolic alkalosis results from a loss of acid or an increase in bicarbonate levels.

Similar Questions