Nursing Elites

1. Following admission for cardiac catheterization, the nurse is providing discharge teaching to the parents of a 2-year-old toddler with tetralogy of Fallot. What instruction should the nurse give the parents if their child becomes pale, cool, and lethargic?

• A. Encourage oral electrolyte solution intake
• B. Assist the child to a recumbent position
• C. Contact their healthcare provider immediately
• D. Provide a quiet time by holding or rocking the toddler

Correct answer: C

Rationale: If a child with tetralogy of Fallot becomes pale, cool, and lethargic, these symptoms may indicate a hypoxic episode or worsening condition. It is crucial to contact the healthcare provider immediately for further evaluation and management to ensure the child's safety and well-being. Option A is incorrect because electrolyte solution intake is not the immediate action needed for these symptoms. Option B is incorrect as positioning alone may not address the underlying issue. Option D is incorrect as providing a quiet time is not appropriate if the child is experiencing concerning symptoms that require prompt medical attention.

2. The nurse is caring for a 4-year-old child who is hospitalized with pneumonia. The child is receiving IV antibiotics and oxygen therapy. The nurse notes that the child’s respiratory rate is 40 breaths per minute, and the oxygen saturation is 92%. What is the nurse’s priority action?

• A. Increase the child’s oxygen flow rate
• B. Notify the healthcare provider
• C. Encourage the child to take deep breaths
• D. Auscultate the child’s lung sounds

Correct answer: D

Rationale: In this scenario, the child is hospitalized with pneumonia, receiving IV antibiotics and oxygen therapy. With a high respiratory rate and decreased oxygen saturation, auscultating the child’s lung sounds is the priority action. This assessment can provide crucial information about the child’s respiratory status, such as the presence of adventitious sounds or decreased air entry, which can guide further interventions and help in evaluating the effectiveness of the current treatments. Increasing the oxygen flow rate may not address the underlying issue causing the decreased oxygen saturation. Notifying the healthcare provider can be necessary but auscultating lung sounds should be done first to gather more information. Encouraging the child to take deep breaths is important for respiratory function but should not be the immediate priority in this situation.

3. What information should be reinforced with the mother of a child with ringworm (Tinea)?

• A. Ringworm is not contagious.
• B. Tinea infections are indicative of poor hygiene and uncleanliness.
• C. Tinea infections are spread by direct and indirect contact.
• D. Ringworm often subsides spontaneously.

Correct answer: C

Rationale: The correct answer is C. Ringworm, a fungal infection, is highly contagious and can be spread by direct contact with infected individuals or animals and indirectly through contaminated objects. It is important for the mother to understand the modes of transmission to prevent the spread of the infection to others and to take necessary precautions to ensure proper treatment and containment of the condition. Choices A and D are incorrect because ringworm is indeed contagious, and it may not always subside spontaneously. Choice B is misleading as tinea infections are not solely indicative of poor hygiene; they can affect anyone, regardless of personal cleanliness.

4. A 7-year-old child with a history of asthma presents to the clinic with shortness of breath and wheezing. The nurse notes that the child’s peak flow reading is in the red zone. What should the nurse do first?

• A. Administer a bronchodilator
• B. Reassess the peak flow reading
• C. Notify the healthcare provider
• D. Provide oxygen therapy

Correct answer: A

Rationale: When a child with asthma presents with shortness of breath and wheezing, and the peak flow reading is in the red zone, indicating severe airflow limitation, the priority intervention is to administer a bronchodilator. Bronchodilators help dilate the airways quickly, improving airflow and assisting with breathing. Reassessing the peak flow reading is important but not the first action to take in a severe asthma exacerbation. Notifying the healthcare provider can be done after initiating immediate treatment with a bronchodilator. Providing oxygen therapy may be needed in some cases, but addressing the airway constriction with a bronchodilator should come first to improve ventilation.

5. A 16-year-old adolescent with cystic fibrosis is admitted to the hospital with a respiratory infection. The nurse is teaching the adolescent about the importance of airway clearance techniques. Which statement by the adolescent indicates a need for further teaching?

• A. I should do my airway clearance exercises every day.
• B. I don’t need to do my airway clearance exercises if I feel okay.
• C. Airway clearance helps prevent mucus buildup in my lungs.
• D. I should continue my airway clearance routine even when I’m not sick.

Correct answer: B

Rationale: The correct answer is B. Airway clearance exercises are essential for individuals with cystic fibrosis to prevent mucus buildup in their lungs. It is crucial to perform these exercises regularly, even when feeling well, to maintain lung health and prevent complications. Choice A is correct as doing airway clearance exercises daily is necessary. Choice C is also accurate as airway clearance does indeed help prevent mucus buildup. Choice D is correct as it is important to continue the airway clearance routine even when not sick to maintain lung health. Choice B is incorrect because stating that airway clearance exercises are unnecessary when feeling okay demonstrates a misunderstanding of the importance of consistent airway clearance in cystic fibrosis management.

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