Nursing Elites

1. An infant with hypertrophic pyloric stenosis (HPS) is admitted to the pediatric unit. What does the nurse expect to find when palpating the infant’s abdomen?

• A. A distended colon
• B. Marked tenderness around the umbilicus
• C. An olive-sized mass in the right upper quadrant
• D. Rhythmic peristaltic waves in the lower abdomen

Correct answer: C

Rationale: When palpating the abdomen of an infant with hypertrophic pyloric stenosis (HPS), the nurse would expect to feel an olive-sized mass in the right upper quadrant. This finding is characteristic of HPS, where the hypertrophied pyloric muscle forms a palpable mass in the abdomen. Choices A, B, and D are incorrect. A distended colon is not a typical finding in HPS, marked tenderness around the umbilicus is not specific to this condition, and rhythmic peristaltic waves in the lower abdomen are not associated with HPS.

2. A nurse is assessing a child with suspected rheumatic fever. What clinical manifestation is the nurse likely to observe?

• A. Jaundice
• B. Peeling skin on the hands and feet
• C. High fever
• D. Severe joint pain

Correct answer: D

Rationale: The correct answer is D, severe joint pain. Rheumatic fever commonly presents with severe joint pain due to joint inflammation. Jaundice (choice A) is not typically associated with rheumatic fever. Peeling skin on the hands and feet (choice B) is more indicative of conditions like Kawasaki disease. While a high fever (choice C) can be present, it is not as specific to rheumatic fever as severe joint pain. Severe joint pain, along with other criteria like carditis, subcutaneous nodules, erythema marginatum, and Sydenham chorea, are major criteria used in the diagnosis of rheumatic fever.

3. An order is written for an isotonic enema for a 2-year-old child. What is the maximum amount of fluid the nurse should administer without a specific order from the healthcare provider?

• A. 100 to 150 mL
• B. 155 to 250 mL
• C. 255 to 360 mL
• D. 365 to 500 mL

Correct answer: B

Rationale: For a 2-year-old child, the maximum recommended amount of fluid for an isotonic enema is between 155 to 250 mL. This range is considered safe to prevent overdistension and potential harm to the child's rectum. Choices A, C, and D exceed the safe range for a 2-year-old child and can lead to complications such as bowel perforation or electrolyte imbalances.

4. A nurse is planning an initial home care visit to a mother who gave birth to a high-risk infant. For what time of day should the nurse schedule the visit for it to be most productive?

• A. When the husband is out of the home.
• B. At a time when the mother is feeding the infant.
• C. At a time that is convenient for the family.
• D. When the nurse can spend time with the family.

Correct answer: C

Rationale: Scheduling the visit at a time that is convenient for the family is the most appropriate choice. This ensures that the family is receptive and available, making the visit more productive. Choice A is incorrect because the presence of the husband may be important for support and decision-making. Choice B focuses solely on the mother and the infant's feeding time, which may not align with the family's overall availability. Choice D is incorrect as it emphasizes the nurse's convenience rather than the family's, which may not lead to an effective visit.

5. A 5-year-old child with a diagnosis of asthma is being evaluated for medication management. What is an important assessment for the nurse to perform?

• A. Assess the child's sleep patterns
• B. Assess the child's dietary intake
• C. Assess the child's academic performance
• D. Assess the child's behavior at home

Correct answer: B

Rationale: Assessing the child's dietary intake is crucial for managing asthma symptoms as certain foods can trigger or worsen asthma attacks. Monitoring dietary intake helps ensure the child receives proper nutrition and avoids triggers. Assessing sleep patterns (Choice A) may be relevant but not as directly impactful on asthma management. Academic performance (Choice C) and behavior at home (Choice D) are important aspects of a child's overall health but are not as directly related to asthma management as dietary intake.

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