Nursing Elites

1. The heart rate for a 3-year-old with a congenital heart defect has steadily decreased over the last few hours, now it's 76 bpm, the previous reading 4 hours ago was 110 bpm. Which additional finding should be reported immediately to a healthcare provider?

• A. Oxygen saturation 94%.
• B. RR of 25 breaths/minute.
• C. Urine output 20 mL/hr.
• D. BP 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. A decrease in blood pressure may suggest poor cardiac output and compromised perfusion, requiring urgent medical attention. The other findings (oxygen saturation of 94%, RR of 25 breaths/minute, and urine output of 20 mL/hr) are within normal ranges for a 3-year-old and do not indicate immediate deterioration of the heart defect.

2. 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 a significant finding indicating a potential health issue that needs immediate attention. It may be a sign of a skin condition, such as a diaper rash, which can cause discomfort and pain for the infant. Addressing this concern promptly is crucial to prevent further complications and ensure the baby's well-being. The other choices may also be important in assessing the overall situation of the family, but in terms of immediate care for the infant, the severe skin breakdown takes priority.

3. The practical nurse is caring for a child with suspected appendicitis. Which assessment finding should be reported to the healthcare provider immediately?

• A. Nausea and vomiting.
• B. Sudden relief of pain.
• C. Low-grade fever.
• D. Rebound tenderness.

Correct answer: B

Rationale: Sudden relief of pain in a child with suspected appendicitis should be reported immediately as it may indicate a rupture of the appendix, which is a medical emergency. Sudden relief of pain is concerning because it can be a sign of a perforated appendix, leading to peritonitis and sepsis.

4. A 3-year-old with HIV infection is staying with a foster family who is caring for 3 other foster children in their home. When one of the children acquires pertussis, the foster mother calls the clinic and asks the nurse what she should do. Which action should the nurse take first?

• A. Remove the child with HIV from the foster home.
• B. Report the exposure of the child with HIV to the health department.
• C. Place the child with HIV in reverse isolation.
• D. Review the immunization documentation of the child with HIV.

Correct answer: D

Rationale: The priority action for the nurse is to review the immunization documentation of the child with HIV. This step ensures that the child has received the necessary vaccines to protect against pertussis and other preventable diseases. It is essential to verify the immunization status to provide appropriate care and prevent further transmission of infectious diseases within the foster home. Removing the child from the foster home (Choice A) may not be necessary if the child is adequately protected through immunization. Reporting the exposure to the health department (Choice B) is important but not the first action. Placing the child in reverse isolation (Choice C) is not indicated for pertussis exposure.

5. The practical nurse is providing care for a toddler who has just returned from surgery for a tonsillectomy. Which intervention is a priority in the immediate postoperative period?

• A. Offer clear fluids frequently.
• B. Encourage the child to cough and deep breathe.
• C. Monitor for frequent swallowing.
• D. Apply a warm compress to the throat area.

Correct answer: C

Rationale: Monitoring for frequent swallowing is a priority intervention in the immediate postoperative period after a tonsillectomy. Frequent swallowing may indicate bleeding from the surgical site, which requires immediate attention to prevent complications such as hemorrhage. Offering clear fluids frequently may not be appropriate immediately after surgery. Encouraging coughing and deep breathing may increase the risk of bleeding. Applying a warm compress to the throat area is not recommended as it can increase blood flow to the surgical site, potentially causing bleeding.

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