Nursing Elites

1. A 3-year-old with a congenital heart defect has had a steady decrease in heart rate, now at 76 bpm from 110 bpm four hours ago. Which additional finding should be reported immediately to a healthcare provider?

• A. Oxygen saturation of 94%.
• B. Respiratory rate of 25 breaths/minute.
• C. Urine output of 20 mL/hr.
• D. Blood pressure of 70/40.

Correct answer: D

Rationale: A significant drop in heart rate and blood pressure should be reported immediately as it may indicate worsening of the congenital heart defect. The blood pressure of 70/40 is dangerously low and requires immediate attention to prevent further complications. Oxygen saturation of 94% is within an acceptable range and does not indicate immediate danger. A respiratory rate of 25 breaths/minute is slightly elevated but not a critical finding. Urine output of 20 mL/hr is low but may not be the most concerning finding in this scenario compared to the drop in blood pressure.

2. A 12-year-old male is brought to the clinic after falling during a skateboarding trick. The child's vital signs are heart rate 135 beats/minute, respirations 20 breaths/minute, and blood pressure 90/60. Which finding should the practical nurse report to the healthcare provider immediately?

• A. The client complains of his back being sore.
• B. Capillary refill is less than 2 seconds.
• C. Blood pressure is 94/68.
• D. Peripheral pulses are weak and rapid.

Correct answer: D

Rationale: In this scenario, the 12-year-old male with a heart rate of 135 beats/minute, respirations of 20 breaths/minute, and blood pressure of 90/60 after falling during a skateboarding trick exhibits signs of shock. Weak and rapid peripheral pulses are concerning as they may indicate decreased cardiac output and tissue perfusion, which are signs of shock. This finding should be reported to the healthcare provider immediately for further evaluation and intervention to prevent potential complications. The other choices are less urgent. Complaints of back soreness (choice A) could be related to musculoskeletal injury. Capillary refill less than 2 seconds (choice B) is within the normal range, indicating adequate peripheral perfusion. A blood pressure of 94/68 (choice C) is slightly higher than the initial reading and may be compensatory in response to the fall and shock state.

3. A 16-year-old female student with a history of asthma controlled with both an oral antihistamine and an albuterol (ProAir) metered-dose inhaler (MDI) comes to the school nurse. The student complains that she cannot sleep at night, feels shaky, and her heart feels like it is 'beating a mile a minute.' Which information is most important for the nurse to obtain?

• A. When she last took the antihistamine.
• B. When her last asthma attack occurred.
• C. Duration of most asthma attacks.
• D. How often the MDI is used daily.

Correct answer: D

Rationale: The most crucial information for the nurse to obtain in this scenario is how often the metered-dose inhaler (MDI) is used daily. This information will help assess if the symptoms of insomnia, shakiness, and palpitations are potentially related to overuse of the inhaler, which can cause side effects such as tremors and palpitations. Monitoring the frequency of MDI usage is essential in managing asthma and ensuring appropriate medication administration.

4. A 7-year-old child with type 1 diabetes is brought to the emergency department with abdominal pain, nausea, and vomiting. The nurse notes that the child's blood glucose level is 350 mg/dL. What should the nurse do first?

• A. Administer IV fluids as prescribed
• B. Administer insulin as prescribed
• C. Monitor the child's urine output
• D. Check the child's urine for ketones

Correct answer: A

Rationale: In a child with type 1 diabetes presenting with abdominal pain, nausea, vomiting, and a high blood glucose level, the priority is to administer IV fluids to correct dehydration and electrolyte imbalances, which are crucial in managing diabetic ketoacidosis. Administering insulin without addressing fluid deficits can lead to further complications. While monitoring urine output and checking for ketones are important steps in the care of a child with diabetes, the immediate focus should be on correcting dehydration and electrolyte imbalances through IV fluid administration to stabilize the child's condition.

5. A mother brings her 3-month-old infant to the clinic because the baby does not sleep through the night. Which finding is most significant in planning care for this family?

• A. The mother is a single parent and lives with her parents
• B. The mother states the baby is irritable during feedings
• C. The infant's formula has been changed twice
• D. The diaper area shows severe skin breakdown

Correct answer: D

Rationale: Severe skin breakdown in the diaper area is significant as it indicates a potential severe issue that needs immediate attention to prevent further complications. Skin breakdown can lead to infections and discomfort for the infant, making it a priority in planning care for this family. The other findings, such as the mother's living situation, baby's irritability during feedings, or formula changes, are important but do not pose immediate risks to the infant's health compared to severe skin breakdown.

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