Nursing Elites

1. After reinforcing information on treating a sprained ankle, what statement by the adolescent indicates to the practical nurse that further instruction is needed?

• A. Keep the leg elevated when sitting.
• B. Wrap the ankle in an elastic bandage for support.
• C. Apply warm compresses to the ankle for the first 24 hours.
• D. Put an ice pack on the ankle, alternating 30 minutes on and 30 minutes off.

Correct answer: C

Rationale: The correct answer is C. Applying warm compresses to a sprained ankle within the first 24 hours is incorrect as it can increase swelling and inflammation. Instead, cold compresses are recommended to help reduce swelling and pain. Option A, keeping the leg elevated, helps in reducing swelling. Option B, wrapping the ankle in an elastic bandage, provides support. Option D, using an ice pack in intervals, is effective in reducing swelling and pain. Therefore, the statement about applying warm compresses indicates the need for further instruction.

2. The mother of a 4-month-old asks the nurse for advice in preventing diaper rash. What suggestion should the nurse provide?

• A. At diaper change generously powder the baby's diaper area with talcum powder to promote dryness.
• B. Wash the diaper area every 2 hours with soap and water to help prevent skin breakdown.
• C. Use a barrier cream, such as zinc oxide, which does not have to be completely removed with each diaper change.
• D. Place a cloth diaper inside the disposable diaper for overnight periods when increased wearing time is likely.

Correct answer: C

Rationale: Using a barrier cream like zinc oxide protects the skin and helps prevent diaper rash.

3. The caregiver discovers a 6-month-old infant unresponsive and calls for help. After opening the airway and finding the infant is still not breathing, what action should the caregiver take?

• A. Palpate femoral pulse and check for regularity.
• B. Deliver cycles of 30 chest compressions and 2 breaths.
• C. Give two breaths that make the chest rise.
• D. Feel the carotid pulse and check for adequate breathing.

Correct answer: C

Rationale: Providing two breaths that make the chest rise is the correct action in this situation. This helps to deliver oxygen to the infant's lungs and body, which is crucial in a situation where the infant is not breathing. Chest rise indicates successful ventilation, and it is an essential step in pediatric resuscitation, especially for infants. Choices A, B, and D are incorrect because palpating the femoral pulse, delivering chest compressions, and feeling the carotid pulse are not the initial actions to take when an infant is not breathing. The priority is to provide effective breaths to establish ventilation.

4. During a follow-up clinical visit, a mother tells the nurse that her 5-month-old son, who had surgical correction for tetralogy of Fallot, has rapid breathing, often takes a long time to eat, and requires frequent rest periods. The infant is not crying while being held, and his growth is in the expected range. Which intervention should the nurse implement?

• A. Stimulate the infant to cry to produce cyanosis
• B. Auscultate the heart and lungs while holding the infant
• C. Evaluate the infant for failure to thrive
• D. Obtain a 12-lead electrocardiogram

Correct answer: B

Rationale: Auscultating the heart and lungs while the infant is held is the most appropriate intervention to assess his current condition. This action allows the nurse to gather important information regarding the cardiovascular and respiratory status of the infant, which is crucial in evaluating his post-surgical recovery and overall well-being. Option A is incorrect as stimulating the infant to cry intentionally is not necessary and could cause distress. Option C is incorrect as the infant's growth is within the expected range, indicating no signs of failure to thrive. Option D is incorrect as obtaining a 12-lead electrocardiogram is not the initial intervention needed in this situation; assessing the heart and lungs through auscultation is more immediate and informative.

5. A mother brings her 3-month-old infant to the clinic because the baby does not sleep through the night. Which finding is most significant in planning care for this family?

• A. The mother is a single parent and lives with her parents
• B. The mother states the baby is irritable during feedings
• C. The infant's formula has been changed twice
• D. The diaper area shows severe skin breakdown

Correct answer: D

Rationale: Severe skin breakdown in the diaper area is significant as it indicates a potential severe issue that needs immediate attention to prevent further complications. Skin breakdown can lead to infections and discomfort for the infant, making it a priority in planning care for this family. The other findings, such as the mother's living situation, baby's irritability during feedings, or formula changes, are important but do not pose immediate risks to the infant's health compared to severe skin breakdown.

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