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. Which nursing intervention should be included in the postoperative care of a child following a tonsillectomy?

• A. Encourage the child to blow the nose gently
• B. Notify the physician if mucus is observed in the emesis
• C. Position the child supine in the immediate postoperative period
• D. Avoid giving citrus juice

Correct answer: D

Rationale: The correct answer is D: 'Avoid giving citrus juice.' Citrus juice can irritate the throat after a tonsillectomy, so it should be avoided. Choice A is incorrect because blowing the nose gently is not a recommended intervention following a tonsillectomy. Choice B is incorrect as mucus in emesis is not uncommon postoperatively and does not necessarily require physician notification. Choice C is incorrect as positioning the child supine immediately postoperatively can increase the risk of airway obstruction and should be avoided.

3. When taking a child’s blood pressure, what percentage of the upper arm should the nurse ensure the cuff bladder width covers?

• A. 20%
• B. 40%
• C. 60%
• D. 80%

Correct answer: B

Rationale: When taking a child's blood pressure, the nurse should select a cuff with a bladder width that covers 40% of the arm circumference at the midpoint of the upper arm. This ensures accurate readings. Choosing a cuff that covers less or more than 40% can lead to incorrect blood pressure measurements. Therefore, options A, C, and D are incorrect.

4. What amount of fluid loss occurs with moderate dehydration?

• A. <50 ml/kg
• B. 50 to 90 ml/kg
• C. <5% total body weight
• D. >15% total body weight

Correct answer: B

Rationale: Moderate dehydration is typically defined as a loss of 50 to 90 mL/kg of body weight. This amount reflects significant fluid loss that requires medical attention but is not yet severe.

5. The nurse is performing an assessment on a 10-week-old infant. The nurse understands that the developmental characteristic of hearing at this age is which?

• A. The infant responds to his own name.
• B. The infant localizes sounds by turning his head directly to the sound.
• C. The infant turns his head to the side when sound is made at the level of the ear.
• D. The infant locates sound by turning his head to the side and then looking up or down.

Correct answer: C

Rationale: By 10 weeks, infants typically turn their heads to the side to locate the source of a sound made at ear level.

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