Nursing Elites

1. An infant with congestive heart failure is receiving diuretic therapy. A nurse is closely monitoring the intake and output. The nurse uses which most appropriate method to assess the urine output?

• A. Weighing the diapers
• B. Inserting a Foley catheter
• C. Comparing intake with output
• D. Measuring the amount of water added to formula

Correct answer: A

Rationale: Weighing the diapers is the most appropriate method to assess urine output in infants. Diapers will absorb and retain urine, providing a measurable indicator of urine output without invasive procedures. This method is non-invasive, simple, and convenient for monitoring urine output, especially in infants who may not be able to use other urine output measurement techniques. Inserting a Foley catheter is invasive and not indicated for routine urine output monitoring in infants. Comparing intake with output does not directly measure urine output. Measuring the amount of water added to formula does not provide an accurate assessment of urine output.

2. During the pediatric assessment process, which scenario would be the LEAST appropriate for the transition phase?

• A. A parent is available to help keep the child calm.
• B. The child is unstable and needs rapid transport.
• C. You determine that the child's condition is stable.
• D. Your transport time is greater than 30 minutes.

Correct answer: B

Rationale: During a pediatric assessment, the transition phase is a critical period where care is handed over from prehospital providers to the hospital team. If the child is unstable and requires rapid transport, it is not appropriate to delay for a transition phase. In such cases, immediate transport to a higher level of care is paramount to ensure the child's safety and well-being. Choice A is appropriate as having a parent present can help keep the child calm during the transition. Choice C is also appropriate as transitioning a stable child allows for a smoother handover. Choice D, while indicating a longer transport time, does not necessarily affect the need for a transition phase as long as the child's condition remains stable.

3. Warning signs that indicate dehydration include all EXCEPT:

• A. Poor skin turgor
• B. Increased urine output
• C. Tachycardia
• D. Eager to drink

Correct answer: B

Rationale: The correct answer is B. Increased urine output is not a warning sign of dehydration; it typically decreases with dehydration. Dehydration often presents with poor skin turgor, tachycardia, and an increased sensation of thirst (eager to drink) as the body tries to compensate for fluid loss. Choices A, C, and D are all correct warning signs of dehydration. Poor skin turgor is a result of decreased skin elasticity due to fluid loss. Tachycardia, an elevated heart rate, can be a compensatory mechanism to maintain cardiac output in dehydration. Feeling eager to drink is a common symptom of dehydration as the body attempts to restore fluid balance.

4. After providing home care instructions to the mother of a child being discharged following cardiac surgery, which statement made by the mother indicates a need for further instructions?

• A. A balance of rest and exercise is important.
• B. I can apply lotion or powder to the incision if it is itchy.
• C. Activities in which falling could occur need to be avoided for two to four weeks.
• D. Large crowds of people need to be avoided for at least two weeks after the surgery.

Correct answer: B

Rationale: The correct answer is B. The mother stating that she can apply lotion or powder to the incision if it is itchy indicates a need for further instructions. Applying lotion or powder to the incision is not recommended as it can increase the risk of infection. The other choices are correct: A) Balancing rest and exercise is important for recovery, C) avoiding activities where falling could occur is necessary to prevent injury, and D) avoiding large crowds helps reduce the risk of infections during the initial recovery period.

5. When performing CPR on an infant with suspected sudden infant death syndrome (SIDS), an important aspect to consider is:

• A. Focusing all of your attention on the infant, with minimal parental interaction.
• B. Carefully inspecting the environment in which the infant was found.
• C. Understanding that most infants with SIDS can be successfully resuscitated.
• D. Encouraging the presence of the parents during your resuscitation attempt.

Correct answer: B

Rationale: When dealing with a suspected case of SIDS, it is crucial to carefully inspect the environment in which the infant was found. This inspection can provide valuable information that may help determine the cause and support further investigation into the incident. By examining the surroundings, potential hazards or clues related to the sudden event may be identified, aiding in understanding the circumstances and potentially preventing similar incidents in the future.

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