Nursing Elites

1. An 8-year-old child is placed in 90-90 traction for a fractured femur. The nurse notices that the weights are touching the foot of the bed. What action should the nurse take?

• A. No bowel movement for two days
• B. Mother helps reposition the child
• C. Ensure weights are not touching the foot of the bed
• D. Child wiggles toes freely when tickled

Correct answer: C

Rationale: The nurse should ensure that the weights in traction are not touching the foot of the bed. This is crucial to maintain proper alignment and effectiveness of the traction. When the weights touch the bed, it can compromise the traction's function and delay healing. Choices A, B, and D are incorrect as they do not address the issue of ensuring that the weights are not touching the bed, which is essential for the traction to work effectively.

2. Rehabilitation after illness is classified under which level of healthcare?

• A. Primary
• B. Secondary
• C. Tertiary
• D. All three

Correct answer: C

Rationale: Rehabilitation after illness is classified as tertiary care. Tertiary care aims to help patients recover from illness, injuries, or disabilities, and restore their functionality. Primary care involves preventive measures and early disease detection, while secondary care focuses on diagnosis and treatment of specific conditions. Therefore, choices A, B, and D are incorrect as they do not specifically address the specialized nature of rehabilitation in healthcare.

3. What is the primary cause of diabetic ketoacidosis (DKA)?

• A. Insulin deficiency
• B. Overhydration
• C. Excess carbohydrate intake
• D. Excess insulin

Correct answer: A

Rationale: The correct answer is A: Insulin deficiency. Diabetic ketoacidosis occurs due to a severe lack of insulin, causing the body to break down fat for energy, leading to the production of ketones and acidification of the blood. Option B, Overhydration, is incorrect as DKA is characterized by dehydration rather than overhydration. Option C, Excess carbohydrate intake, is incorrect because while high blood sugar levels can contribute to DKA, the primary cause is insulin deficiency. Option D, Excess insulin, is also incorrect as DKA is not caused by an excess of insulin but rather by a lack of it.

4. A new mother who is breastfeeding her newborn for the first time after delivery reports nipple pain when the baby sucks. Based on this client problem, which action should the PN take?

• A. Ensure that all the areolar tissue of the nipple is in the infant's mouth
• B. Have the mother reposition the infant from the cradle to the football hold
• C. Check for engorgement and assess the nipples for cracks or lesions
• D. Apply a warm compress to the breast for 10 minutes before each feeding

Correct answer: A

Rationale: Proper latch, including all the areolar tissue in the infant's mouth, is essential to prevent nipple pain and ensure effective breastfeeding. Option A is correct because ensuring that all the areolar tissue of the nipple is in the infant's mouth helps achieve a good latch, reducing nipple pain. Option B is incorrect as repositioning the infant may not address the root cause of the pain related to latch issues. Option C is incorrect because while checking for engorgement and nipple issues is important, it does not directly address the latch concern causing the pain. Option D is incorrect as applying a warm compress is not recommended for breastfeeding mothers; a warm compress can help with pain associated with engorgement, but it does not address latch issues.

5. A full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic. Which immediate intervention should the PN implement?

• A. Stimulate the infant to cry
• B. Give oxygen by positive pressure
• C. Suction the oral and nasal passages
• D. Turn the infant onto the right side

Correct answer: C

Rationale: Suctioning the oral and nasal passages is the correct immediate intervention in this scenario. Regurgitation leading to cyanosis indicates a potential airway obstruction, which requires prompt action to clear. Stimulating the infant to cry (Choice A) may not address the underlying issue of airway obstruction. Giving oxygen by positive pressure (Choice B) can be beneficial, but clearing the airway obstruction takes precedence. Turning the infant onto the right side (Choice D) does not directly address the need to clear the airway.

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