Nursing Elites

1. A nurse is planning care for a 2-month-old infant who is postoperative following surgical repair of a cleft lip. Which of the following actions should the nurse take?

• A. Position the infant on his abdomen
• B. Cleanse the incision site with hydrogen peroxide
• C. Offer the infant a pacifier
• D. Keep the infant's elbow restrained

Correct answer: D

Rationale: The nurse should keep the infant�s elbow restrained to prevent injury to the surgical site.

2. Which statement by the parents indicates understanding of the process involved with a kidney transplant for a child with renal failure?

• A. We are happy that our child will not have to take any more medicine after the transplant.
• B. We understand that our child will not be at risk anymore for catching colds from other children at school.
• C. We will be glad that we will not have to bring our child in to see the doctor again.
• D. We know it is important to ensure that our child takes prescribed medications after the transplant.

Correct answer: D

Rationale: The correct answer is D because parents should understand the importance of medication adherence post-transplant to prevent rejection. Following the prescribed medication regimen is crucial for the success of the kidney transplant and the overall health of the child. Monitoring and ensuring the child takes their medications as directed by the healthcare provider are essential components of post-transplant care. Choices A, B, and C are incorrect because they do not address the critical aspect of medication management post-transplant, which is vital for the child's well-being and the success of the procedure.

3. When planning care for a pediatric client diagnosed with bacterial meningitis, what is the priority nursing diagnosis?

• A. Impaired Gas Exchange
• B. Risk for Infection
• C. Anxiety (parental)
• D. Acute Pain

Correct answer: A

Rationale: The priority nursing diagnosis when caring for a pediatric client with bacterial meningitis is 'Impaired Gas Exchange.' This diagnosis takes precedence due to the potential for respiratory complications associated with the condition. Bacterial meningitis can lead to increased intracranial pressure, compromising the child's ability to ventilate adequately. Therefore, monitoring and addressing any signs of respiratory distress are crucial in the care of these patients.

4. Marge is a 2-year-old girl who does not sit and eat at mealtimes but rather brings food to many rooms, eats a few bites, and drops it. Her parents report that she is a 'fussy eater.' Marge is significantly below weight for her age. She does not have any oral motor structure abnormalities, but eats only certain foods with the same texture. Which intervention strategy would be best to address the environmental context?

• A. Prolong mealtimes and eliminate all snacks
• B. Provide high-calorie snacks and meals at the table throughout the day
• C. Allow Marge to eat whenever and wherever she wants in the house
• D. Require Marge to eat everything on her plate and at snack

Correct answer: B

Rationale: In the case of Marge, who exhibits selective eating habits and struggles with weight gain, providing high-calorie snacks and meals at the table throughout the day can be an effective intervention. This strategy can help increase her food intake in a structured environment, promoting healthier eating habits and potentially addressing her below-average weight status. Choice A, prolonging mealtimes and eliminating all snacks, may not be the best approach as it could lead to more food refusal and stress during meals. Choice C, allowing Marge to eat whenever and wherever she wants in the house, may further enable her selective eating behavior and hinder progress. Choice D, requiring Marge to eat everything on her plate and at snack, can create a negative mealtime environment and may not address the underlying causes of her eating habits. Therefore, providing high-calorie snacks and meals at designated times offers a balanced approach to support Marge's nutritional needs and overall well-being.

5. When educating a parent of an infant with a new prescription for digoxin, which instruction should the nurse provide?

• A. Repeat the dose if the infant vomits.
• B. Mix the medication with food.
• C. Give the medication with meals.
• D. Monitor the infant's heart rate prior to administering the medication.

Correct answer: D

Rationale: The correct answer is D: 'Monitor the infant's heart rate prior to administering the medication.' It is crucial for the nurse to monitor the infant's heart rate before giving digoxin to identify any signs of digoxin toxicity early. Heart rate assessment helps in detecting and preventing potential complications associated with digoxin use. Choices A, B, and C are incorrect. Repeating the dose if the infant vomits can lead to overdose, mixing the medication with food may alter its absorption, and giving the medication with meals can affect its effectiveness. Therefore, the priority is to monitor the infant's heart rate to ensure safe administration of digoxin.

Similar Questions