Nursing Elites

1. When planning the discharge of a child who had surgery for a congenital heart defect, what is an important aspect of the discharge teaching?

• A. Teaching the parents about signs of infection
• B. Providing instructions on wound care
• C. Scheduling follow-up appointments
• D. Explaining the use of prescribed medications

Correct answer: D

Rationale: Explaining the use of prescribed medications is crucial because it helps ensure proper management of the child’s condition after discharge. While teaching the parents about signs of infection and providing instructions on wound care are important aspects of postoperative care, they are not as critical as ensuring the correct understanding and administration of prescribed medications. Scheduling follow-up appointments is also important but does not directly impact the immediate post-discharge care and medication adherence.

2. What is the priority nursing intervention for a child admitted to the hospital with a diagnosis of acute glomerulonephritis?

• A. Monitoring for hypertension
• B. Providing pain relief
• C. Restricting fluid intake
• D. Encouraging fluid intake

Correct answer: A

Rationale: The priority nursing intervention for a child with acute glomerulonephritis is monitoring for hypertension. Acute glomerulonephritis involves inflammation of the kidney's glomeruli, leading to impaired kidney function. Hypertension is a common complication due to fluid retention and increased renin-angiotensin system activity. Monitoring for hypertension is crucial for early detection and management to prevent further kidney damage and complications. Providing pain relief (Choice B) may be required for discomfort but is not the priority. Restricting fluid intake (Choice C) may be necessary in some kidney diseases, but in acute glomerulonephritis, the focus is on monitoring and managing hypertension. Encouraging fluid intake (Choice D) is inappropriate as it can exacerbate fluid overload and hypertension in acute glomerulonephritis.

3. A nurse is reviewing the laboratory report of a child with tetralogy of Fallot that indicates an elevated RBC count. What does the nurse identify as the cause of the polycythemia?

• A. Low tissue oxygen needs
• B. Tissue oxygen needs
• C. Diminished iron levels
• D. Hypertrophic cardiac muscle

Correct answer: B

Rationale: The correct answer is B: Tissue oxygen needs. Polycythemia occurs in response to chronic hypoxia, leading the body to increase red blood cell production to enhance oxygen delivery. In tetralogy of Fallot, a congenital heart defect that results in reduced oxygen levels in the blood, the body compensates by producing more red blood cells. Choice A is incorrect as low tissue oxygen needs would not trigger polycythemia. Choice C, diminished iron levels, is not the cause of polycythemia in this case. Choice D, hypertrophic cardiac muscle, is unrelated to the pathophysiology of polycythemia in tetralogy of Fallot.

4. The nurse is caring for an infant with suspected pyloric stenosis. Which clinical manifestation would indicate pyloric stenosis?

• A. abdominal rigidity and pain on palpation
• B. rounded abdomen and hypoactive bowel sounds
• C. visible peristalsis and weight loss
• D. distention of the lower abdomen and constipation

Correct answer: C

Rationale: Visible peristalsis and weight loss are classic clinical manifestations of pyloric stenosis. The obstruction at the pyloric sphincter causes visible peristalsis as the stomach tries to push food through the narrowed opening, leading to the appearance of waves across the abdomen. Weight loss occurs due to poor feeding and frequent vomiting associated with pyloric stenosis. Choices A, B, and D are incorrect. Abdominal rigidity and pain on palpation, rounded abdomen and hypoactive bowel sounds, as well as distention of the lower abdomen and constipation are not typically seen in pyloric stenosis.

5. An order is written for an isotonic enema for a 2-year-old child. What is the maximum amount of fluid the nurse should administer without a specific order from the healthcare provider?

• A. 100 to 150 mL
• B. 155 to 250 mL
• C. 255 to 360 mL
• D. 365 to 500 mL

Correct answer: B

Rationale: For a 2-year-old child, the maximum recommended amount of fluid for an isotonic enema is between 155 to 250 mL. This range is considered safe to prevent overdistension and potential harm to the child's rectum. Choices A, C, and D exceed the safe range for a 2-year-old child and can lead to complications such as bowel perforation or electrolyte imbalances.

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