Nursing Elites

1. Fred is a 12-year-old boy diagnosed with pneumococcal pneumonia. Which of the following would Nurse Nica expect to assess?

• A. Mild cough
• B. Slight fever
• C. Chest pain
• D. Bulging fontanel

Correct answer: C

Rationale: Chest pain is a common symptom seen in patients with pneumococcal pneumonia. It can result from inflammation of the pleura or irritation of the diaphragm due to the infection. While cough and fever are also common symptoms, chest pain is particularly significant in pneumonia cases as it can be a distressing symptom for the patient and may indicate complications or severity of the infection. Bulging fontanel, on the other hand, is more indicative of conditions affecting infants and is not typically associated with pneumococcal pneumonia in a 12-year-old boy.

2. 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.

3. An 18-month-old child presents with fever, nasal flaring, intercostal retractions, and a respiratory rate of 50 bpm. What is the most appropriate nursing diagnosis?

• A. High risk for altered body temperature (hyperthermia)
• B. Ineffective breathing pattern
• C. Ineffective individual coping
• D. Knowledge deficit

Correct answer: B

Rationale: The most appropriate nursing diagnosis for the 18-month-old child presenting with fever, nasal flaring, intercostal retractions, and a respiratory rate of 50 bpm is 'Ineffective breathing pattern.' These symptoms collectively indicate respiratory distress, which aligns with the nursing diagnosis of ineffective breathing pattern. Nasal flaring, intercostal retractions, and an increased respiratory rate are signs of respiratory distress in pediatric patients, suggesting the need for immediate intervention to address the underlying breathing difficulties.

4. You and your partner are performing CPR on a 2-year-old female in cardiac arrest. During your resuscitation attempt, you should:

• A. hyperventilate her due to severe hypoxia.
• B. attach the AED pads after 5 minutes of high-quality CPR.
• C. perform compressions and ventilations at a ratio of 30:2.
• D. allow the chest to fully recoil between compressions.

Correct answer: D

Rationale: Allowing the chest to fully recoil between compressions is crucial during CPR to ensure proper blood flow. This action allows the heart to refill with blood, enhancing the effectiveness of compressions and circulation. Hyperventilating the patient can lead to decreased cardiac output and is not recommended. Attaching AED pads should be done as soon as possible in a pediatric cardiac arrest situation, ideally within 2 minutes. The correct compression-to-ventilation ratio for pediatric CPR is 30:2, focusing on high-quality compressions to provide adequate perfusion to vital organs.

5. A new mother expresses concern about her baby's frequent hiccups. What should the nurse explain about newborn hiccups?

• A. Hiccups are a sign of respiratory distress in newborns.
• B. Hiccups indicate the baby is overeating.
• C. Hiccups are common and usually harmless in newborns.
• D. Hiccups are caused by a lack of burping.

Correct answer: C

Rationale: Newborn hiccups are common and usually harmless. They are typically caused by the baby's immature diaphragm and tend to resolve on their own. It is essential for parents to understand that hiccups in newborns are a normal phenomenon and do not necessarily indicate any underlying health issue. Choice A is incorrect because hiccups are not a sign of respiratory distress in newborns. Choice B is incorrect as hiccups do not indicate the baby is overeating. Choice D is also incorrect as hiccups are not solely caused by a lack of burping.

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