Nursing Elites

1. After providing home care instructions to the mother of a child being discharged following cardiac surgery, which statement made by the mother indicates a need for further instructions?

• A. A balance of rest and exercise is important.
• B. I can apply lotion or powder to the incision if it is itchy.
• C. Activities in which falling could occur need to be avoided for two to four weeks.
• D. Large crowds of people need to be avoided for at least two weeks after the surgery.

Correct answer: B

Rationale: The correct answer is B. The mother stating that she can apply lotion or powder to the incision if it is itchy indicates a need for further instructions. Applying lotion or powder to the incision is not recommended as it can increase the risk of infection. The other choices are correct: A) Balancing rest and exercise is important for recovery, C) avoiding activities where falling could occur is necessary to prevent injury, and D) avoiding large crowds helps reduce the risk of infections during the initial recovery period.

2. Which of the following statements regarding sudden infant death syndrome (SIDS) is correct?

• A. Death as a result of SIDS can occur at any time of the day or night.
• B. Certain cases of SIDS are predictable and therefore preventable.
• C. Most cases of SIDS occur in infants younger than 6 months.
• D. SIDS is uncommon in infants older than 1 year of age.

Correct answer: A

Rationale: The correct answer is A. SIDS can occur at any time of the day or night, although it most commonly occurs during sleep. SIDS is sudden and unpredictable, making it challenging to prevent in all cases. While most cases occur in infants younger than 6 months, it is not limited to this age group. SIDS is not uncommon in infants older than 1 year of age, although less common than in younger infants.

3. Which behavior is most indicative that a 2-year-old is experiencing the initial phase of separation anxiety because his parents cannot stay all day at the hospital with him?

• A. He withdraws from the nursing staff.
• B. He cries when his parents leave.
• C. He lies quietly in bed.
• D. He cries when his parents arrive.

Correct answer: B

Rationale: The most indicative behavior of a 2-year-old experiencing the initial phase of separation anxiety due to parents not staying all day at the hospital is crying when his parents leave. This behavior is a common manifestation of separation anxiety in children, as they struggle with the absence of their primary attachment figures. Choices A, C, and D are less indicative because withdrawing from the nursing staff, lying quietly in bed, or crying when parents arrive do not specifically demonstrate the distress caused by separation from parents, which is the hallmark of separation anxiety in children.

4. What is the appropriate ventilation rate for an apneic infant?

• A. 8 to 10 breaths/min.
• B. 10 to 12 breaths/min.
• C. 12 to 20 breaths/min.
• D. 20 to 30 breaths/min.

Correct answer: C

Rationale: During resuscitation of an apneic infant, the appropriate ventilation rate is 12 to 20 breaths per minute. This rate helps provide adequate oxygenation and ventilation without causing harm to the infant. Choice A (8 to 10 breaths/min) is too low and may not provide sufficient ventilation. Choice B (10 to 12 breaths/min) is slightly below the recommended range, which may not be optimal for effective resuscitation. Choice D (20 to 30 breaths/min) is too high and may lead to overventilation and potential harm to the infant by causing hypocapnia.

5. A 3-month-old is hospitalized with a fractured femur. The pain assessment tool most appropriate for this child is the:

• A. FLACC scale.
• B. Poker chip tool.
• C. Number scale.
• D. Visual analog scale.

Correct answer: A

Rationale: The FLACC scale is a validated pain assessment tool suitable for infants and young children, including 3-month-olds. It assesses pain based on five categories: Face, Legs, Activity, Cry, and Consolability. Since infants cannot communicate their pain verbally, the FLACC scale is effective in evaluating pain by observing these behavioral indicators. The other options, such as the Poker chip tool, Number scale, and Visual analog scale, are not specifically designed for infants and may not provide accurate pain assessment in this age group.

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