Nursing Elites

1. A healthcare provider is assessing a 3-month-old infant with suspected pyloric stenosis. What clinical manifestation is the healthcare provider likely to observe?

• A. Projectile vomiting
• B. Diarrhea
• C. Constipation
• D. Abdominal distension

Correct answer: A

Rationale: Projectile vomiting is a classic clinical manifestation of pyloric stenosis in infants. This occurs due to the narrowing of the pyloric sphincter, leading to the forceful expulsion of gastric contents in a projectile manner. Diarrhea (choice B) is not typically associated with pyloric stenosis. Constipation (choice C) is also not a common symptom of this condition. Abdominal distension (choice D) may occur in pyloric stenosis but is not as specific or characteristic as projectile vomiting in diagnosing this condition.

2. During a health assessment of a school-age child, where should the nurse focus more attention based on the child's developmental level?

• A. Infections
• B. Poisonings
• C. Risk-taking behaviors
• D. Accidents and injuries

Correct answer: D

Rationale: During the school-age period, children are active, curious, and engaged in various physical activities, making them more susceptible to accidents and injuries. This developmental stage is characterized by increased motor skills and exploration, leading to a higher risk of unintentional harm. While infections, poisonings, and risk-taking behaviors are also concerns for school-age children, focusing on preventing and addressing accidents and injuries is essential due to their heightened physical activity and curiosity.

3. What clinical manifestation of tetralogy of Fallot should the nurse expect when caring for children with this diagnosis?

• A. Slow respirations
• B. Clubbing of fingers
• C. Decreased RBC counts
• D. Subcutaneous hemorrhages

Correct answer: B

Rationale: Clubbing of fingers is a common manifestation in children with tetralogy of Fallot due to chronic hypoxia. Clubbing occurs as a result of long-standing decreased oxygen levels in the blood, leading to changes in the fingertips. Slow respirations (Choice A) are not typically a direct clinical manifestation of tetralogy of Fallot. While decreased RBC counts (Choice C) may occur due to chronic hypoxia, they are not a primary manifestation specific to tetralogy of Fallot. Subcutaneous hemorrhages (Choice D) are not a common clinical manifestation associated with tetralogy of Fallot.

4. When caring for a child diagnosed with bronchiolitis, what is the priority nursing intervention?

• A. Administering bronchodilators
• B. Providing respiratory therapy
• C. Monitoring oxygen saturation
• D. Encouraging fluid intake

Correct answer: B

Rationale: The priority nursing intervention for a child with bronchiolitis is providing respiratory therapy. This intervention aims to maintain airway patency, optimize oxygenation, and support effective breathing. Administering bronchodilators, though important, may not be the initial priority as respiratory therapy takes precedence in ensuring adequate oxygenation and ventilation. Monitoring oxygen saturation is crucial but is usually part of the ongoing assessment following the initiation of respiratory therapy. Encouraging fluid intake is essential for hydration but is not the priority intervention when addressing the respiratory distress associated with bronchiolitis.

5. After clearing the airway of a newborn who is not in distress, what is the most important action for you to take?

• A. Apply free-flow oxygen
• B. Clamp and cut the cord
• C. Keep the newborn warm
• D. Obtain an APGAR score

Correct answer: C

Rationale: Keeping the newborn warm is crucial as newborns are at high risk of hypothermia due to their large body surface area and limited subcutaneous fat. Hypothermia can lead to complications such as respiratory distress, hypoglycemia, and metabolic acidosis. Providing warmth helps maintain the newborn's body temperature and supports physiological processes, promoting overall well-being. Applying free-flow oxygen is not necessary if the newborn is not in distress. Clamping and cutting the cord can be done after addressing the immediate need for warmth. Obtaining an APGAR score is important for assessing the newborn's overall condition but ensuring warmth takes precedence to prevent complications related to hypothermia.

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