Nursing Elites

1. 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.

2. A child with a fever of 39°C (102.2°F) and a sore throat is brought to the clinic. The practical nurse suspects the child has streptococcal pharyngitis. Which diagnostic test should the practical nurse prepare the child for?

• A. Rapid antigen detection test.
• B. Throat culture.
• C. Complete blood count (CBC).
• D. Chest X-ray.

Correct answer: A

Rationale: A rapid antigen detection test is the appropriate diagnostic test for suspected streptococcal pharyngitis. This test is commonly used due to its quick results, helping in the prompt diagnosis and appropriate treatment of the condition. It specifically detects the presence of streptococcal antigens in the throat, aiding in confirming the diagnosis and guiding the healthcare provider in determining the most suitable treatment plan. Throat culture (Choice B) is a confirmatory test but is not as rapid as the rapid antigen detection test. Complete blood count (Choice C) and Chest X-ray (Choice D) are not specific tests for streptococcal pharyngitis and would not aid in confirming the diagnosis.

3. The practical nurse is reinforcing information about Lyme disease prevention with a client who is preparing for a camping trip with family. Which statement by the client informs the nurse that the client understands the instruction?

• A. I'll make sure my son wears dark clothing on his hike.
• B. I'll get a prescription for amoxicillin to take with us.
• C. We should all get the Lyme disease vaccine before our trip.
• D. We will wear long pants and long-sleeved shirts in the woods.

Correct answer: D

Rationale: The correct answer is D. Wearing long pants and long-sleeved shirts is an effective preventive measure against tick bites, which reduces the risk of contracting Lyme disease. This attire helps to minimize skin exposure to ticks, thereby decreasing the chances of a tick attaching and transmitting the disease-causing bacteria.

4. What suggestion should the nurse provide to prevent diaper rash in a 4-month-old infant as requested by the mother?

• A. Generously powder the baby's diaper area with talcum powder at each diaper change 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 forms a protective layer on the skin, creating a barrier against irritants and moisture, thus helping to prevent diaper rash. Unlike other options, barrier creams do not need to be completely removed at each diaper change, allowing the skin to remain protected between changes.

5. A mother brings her 2-year-old son to the clinic because he has been crying and pulling on his earlobe for the past 12 hours. The child’s oral temperature is 101.2°F. Which intervention should the nurse implement?

• A. Ask the mother if the child has had a runny nose
• B. Cleanse purulent exudate from the affected ear canal
• C. Apply a topical antibiotic to the periauricle area
• D. Provide parent education to prevent recurrence

Correct answer: A

Rationale: In a child with ear pain and fever, asking about a runny nose is important to assess if the ear pain is associated with a respiratory infection, such as otitis media. This information can guide further assessment and treatment decisions. Choice B is incorrect because cleansing purulent exudate should be done by a healthcare provider, not the nurse. Choice C is incorrect as topical antibiotics should only be applied under healthcare provider's orders. Choice D is not the priority at this moment, as the immediate concern is assessing the association between the ear pain and a possible respiratory infection.

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