Nursing Elites

1. A two-year-old child with heart failure is admitted for replacement of a graft for coarctation of the aorta. Prior to administering the next dose of digoxin (Lanoxin), the nurse obtains an apical heart rate of 128 bpm. What action should the nurse take?

• A. Determine the pulse deficit.
• B. Administer the scheduled dose.
• C. Calculate the safe dose range.
• D. Review the serum digoxin level.

Correct answer: B

Rationale: Administering the scheduled dose is appropriate in this scenario as the heart rate of 128 bpm falls within the acceptable range for a two-year-old child with heart failure. It indicates that the child may benefit from the therapeutic effects of digoxin. Monitoring the heart rate closely after administration is essential to ensure the medication's effectiveness and safety. Determining the pulse deficit (Choice A) is not necessary in this situation as the heart rate is within the acceptable range. Calculating the safe dose range (Choice C) is not needed since the heart rate is already within the expected parameters. Reviewing the serum digoxin level (Choice D) is not the immediate action required in this case where the heart rate is within the normal range.

2. A 5-year-old child with leukemia is receiving chemotherapy. The nurse notes that the child’s white blood cell count is low. What is the nurse’s priority intervention?

• A. Administer antibiotics as prescribed
• B. Place the child in protective isolation
• C. Encourage the child to eat a balanced diet
• D. Teach the parents about infection prevention

Correct answer: B

Rationale: The priority intervention for a 5-year-old child with leukemia receiving chemotherapy and having a low white blood cell count is to place the child in protective isolation. This intervention helps reduce the risk of infection, which is crucial in this immunocompromised state. Protective isolation aims to limit the child's exposure to pathogens and promote their safety during a period of increased vulnerability to infections.

3. A 13-year-old client with type 1 diabetes is admitted to the hospital with a blood glucose level of 450 mg/dL. The client is lethargic and has fruity-smelling breath. What is the nurse’s priority action?

• A. Administer insulin as prescribed
• B. Start an IV infusion of normal saline
• C. Check the client’s urine for ketones
• D. Monitor the client’s vital signs

Correct answer: B

Rationale: The correct priority action for the nurse is to start an IV infusion of normal saline. The client's presentation with lethargy, fruity-smelling breath, and high blood glucose level indicates diabetic ketoacidosis (DKA). IV fluids are essential to correct dehydration and help stabilize the client's condition. Checking for ketones in the urine is important, but fluid replacement takes precedence to address the immediate risk of dehydration and electrolyte imbalances. Administering insulin is also a crucial intervention for DKA, but fluid resuscitation should first be initiated.

4. A 15-month-old child is brought to the clinic for a routine checkup. The nurse notes that the child is not walking independently yet. What should the nurse do next?

• A. Refer the child for a developmental assessment
• B. Encourage the parents to start physical therapy
• C. Reassure the parents that some children walk later than others
• D. Discuss the importance of early intervention services

Correct answer: C

Rationale: The correct answer is to reassure the parents that some children walk later than others. It is essential to understand that children reach developmental milestones at different ages. Walking independently can occur later in some children, and it is normal. Referring the child for a developmental assessment (Choice A) may cause unnecessary concern at this stage. Encouraging physical therapy (Choice B) or discussing early intervention services (Choice D) may not be warranted unless there are specific concerns identified during the checkup.

5. Following a motor vehicle collision, a 3-year-old girl has a spica cast applied. Which toy is best for the nurse to offer this child?

• A. Duck that squeaks.
• B. Fashion doll and clothes.
• C. Set of cloth and hand puppets.
• D. Handheld video game.

Correct answer: C

Rationale: In this scenario, a set of cloth and hand puppets is the best choice for a 3-year-old with a spica cast. Hand puppets encourage imaginative play, creativity, and interaction, which are developmentally appropriate for a child of this age. The soft materials are safe for the child and can provide entertainment and engagement without posing a risk of injury. The other options, such as a duck that squeaks, a fashion doll and clothes, and a handheld video game, may not be as suitable for a child in a spica cast due to safety concerns, lack of interactive play, or developmental appropriateness.

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