Nursing Elites

1. The mother of an infant diagnosed with bronchiolitis asks the nurse what causes the disease. How should the nurse respond?

• A. Respiratory syncytial virus (RSV)
• B. Haemophilus influenzae
• C. Parainfluenza
• D. Rotavirus

Correct answer: A

Rationale: The correct answer is A: Respiratory syncytial virus (RSV). RSV is the most common cause of bronchiolitis, especially in infants. Bronchiolitis is characterized by inflammation of the small airways in the lungs. Choice B, Haemophilus influenzae, is a bacterium that can cause respiratory infections but is not the primary cause of bronchiolitis. Choice C, Parainfluenza, is a common viral infection that can cause croup and other respiratory illnesses but is not the main cause of bronchiolitis. Choice D, Rotavirus, is a virus that primarily affects the gastrointestinal system, causing diarrhea and vomiting, and is not associated with bronchiolitis.

2. What is an essential nursing care intervention for a neonate with a suspected tracheoesophageal fistula?

• A. Feed glucose water only.
• B. Elevate the patient's head for feedings.
• C. Raise the patient's head and give nothing by mouth.
• D. Avoid suctioning unless the infant is cyanotic.

Correct answer: C

Rationale: Raising the patient’s head and giving nothing by mouth is crucial in managing tracheoesophageal fistula. This intervention helps prevent aspiration and further complications until surgical correction can be performed. Feeding the neonate or suctioning could exacerbate the condition by risking aspiration. Elevating the head for feedings does not address the primary concern of preventing oral intake, making it less appropriate than the correct answer.

3. The nurse determines that a child's intravenous infusion has infiltrated. The infused solution is a vesicant. What is the most appropriate nursing action?

• A. Stop the infusion and apply ice.
• B. End the infusion and notify the practitioner.
• C. Slow the infusion rate and notify the practitioner.
• D. Discontinue the infusion and apply warm compresses.

Correct answer: B

Rationale: If a vesicant solution infiltrates, stopping the infusion immediately and notifying the practitioner is critical to prevent tissue damage. Cold or warm compresses should only be applied following specific medical advice based on the vesicant involved.

4. What is the recommended position for a child with epiglottitis to ease breathing?

• A. Supine
• B. Prone
• C. Tripod
• D. Semi-Fowler’s

Correct answer: C

Rationale: The correct answer is C, 'Tripod.' In children with epiglottitis, the tripod position is recommended to help open the airway and ease breathing. This position involves the child sitting upright, leaning forward, and supporting themselves with their hands on their knees or another surface. This posture helps improve air entry into the lungs by maximizing the space for breathing. Choices A (Supine), B (Prone), and D (Semi-Fowler’s) are incorrect. Placing a child with epiglottitis in the supine position may further obstruct the airway, while the prone position and semi-Fowler’s position do not facilitate optimal air exchange in these cases.

5. Which action should the nurse implement when taking an axillary temperature?

• A. Take the temperature through one layer of clothing
• B. Add a degree to the result when recording
• C. Place the tip of the thermometer under the arm in the center of the axilla
• D. Hold the child's arm away from the body while taking the temperature

Correct answer: C

Rationale: The correct technique involves placing the thermometer tip in the center of the axilla to ensure an accurate reading, with the arm held close to the body.

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