Nursing Elites

1. A patient with acute shortness of breath is admitted to the hospital. Which action should the nurse take during the initial assessment of the patient?

• A. Ask the patient to lie down to complete a full physical assessment.
• B. Briefly ask specific questions about this episode of respiratory distress.
• C. Complete the admission database to check for allergies before treatment.
• D. Delay the physical assessment to first complete pulmonary function tests.

Correct answer: B

Rationale: When a patient presents with acute shortness of breath, the initial assessment should focus on gathering specific information relevant to the current episode of respiratory distress. A comprehensive health history or full physical examination can be deferred until the acute distress has been addressed. Asking specific questions helps determine the cause of the distress and guides appropriate treatment. While checking for allergies is important, completing the entire admission database is not a priority during the initial assessment. Likewise, delaying the physical assessment for pulmonary function tests is not recommended as the immediate focus should be on addressing the acute respiratory distress before ordering further diagnostic tests or interventions.

2. The nurse is preparing to care for an infant who has esophageal atresia with tracheoesophageal fistula. Surgery is scheduled to be performed in 1 hour. Intravenous fluids have been initiated, and a nasogastric (NG) tube has been inserted by the primary healthcare provider. The nurse plans care, knowing that which intervention is of highest priority during this preoperative period?

• A. Monitor the temperature.
• B. Monitor the blood pressure.
• C. Reposition the infant frequently.
• D. Aspirate the NG tube every 5 to 10 minutes.

Correct answer: D

Rationale: Esophageal atresia with tracheoesophageal fistula is a critical neonatal surgical emergency. The highest priority intervention during the preoperative period is to aspirate the NG tube every 5 to 10 minutes to keep the proximal pouch clear of secretions and prevent aspiration. This is crucial in reducing the risk of gastric secretions entering the lungs. Repositioning the infant frequently is not as critical as ensuring the NG tube is aspirated. Monitoring the temperature and blood pressure are important nursing interventions but are not the highest priority in this situation. It is essential to prioritize airway protection and prevent aspiration in this neonate undergoing urgent surgical intervention.

3. The healthcare provider is educating a parent about side effects of routine immunizations. Which of the following must be reported immediately?

• A. Irritability
• B. Slight edema at the injection site
• C. Local tenderness
• D. Temperature of 102.5?F

Correct answer: D

Rationale: A temperature of 102.5°F or higher following immunization is considered an adverse reaction and should be reported immediately. This could indicate a more serious systemic response to the vaccine. Irritability, slight edema at the injection site, and local tenderness are common, mild side effects of routine immunizations and do not typically require immediate reporting. Other reactions that should be reported immediately include excessive crying for more than 3 hours, seizure activity, and the presence of tender, swollen, or reddened areas at the injection site.

4. The parent of an infant diagnosed with gastroesophageal reflux disease is receiving feeding instructions from the nurse. Which instruction should the nurse give to the parent to assist in reducing the episodes of emesis?

• A. Provide smaller, more frequent feedings.
• B. Burp the infant frequently during feedings.
• C. Thin the feedings by adding water to the formula.
• D. Thicken the feedings by adding rice cereal to the formula.

Correct answer: D

Rationale: Gastroesophageal reflux disease involves the backward flow of gastric contents into the esophagus due to sphincter issues. To reduce episodes of emesis, it is recommended to thicken feedings by adding rice cereal to the formula. This helps to weigh down the contents in the stomach, making regurgitation less likely. Providing smaller, more frequent feedings and burping the infant frequently are beneficial strategies for gastroesophageal reflux. However, in this case, thickening the feedings is the most appropriate intervention. Thinning the feedings by adding water to the formula is not recommended as it can decrease the caloric density of the formula and may not help in reducing reflux.

5. The child with hemolytic-uremic syndrome is anuric and will undergo peritoneal dialysis. Which measure should the nurse implement?

• A. Restrict fluids as prescribed.
• B. Care for the arteriovenous fistula.
• C. Encourage foods high in potassium.
• D. Administer analgesics as prescribed.

Correct answer: A

Rationale: In hemolytic-uremic syndrome, often associated with bacterial toxins and viruses, acute kidney injury occurs in children, leading to symptoms like anemia, thrombocytopenia, renal injury, and CNS symptoms. For an anuric child with hemolytic-uremic syndrome undergoing peritoneal dialysis, fluid restriction is vital to prevent fluid overload. Pain management is not directly related to hemolytic-uremic syndrome. Foods high in potassium should be limited, not encouraged, due to impaired kidney function. Peritoneal dialysis does not involve an arteriovenous fistula, which is specific to hemodialysis.

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