Nursing Elites

1. A 6-year-old with muscular dystrophy was recently injured falling out of bed at home. What intervention should the nurse suggest to prevent further injury?

• A. Recommend raising the bed's side rails when a caregiver is not present.
• B. Suggest a caregiver be present continuously to prevent falls from bed.
• C. Encourage the use of loose restraints while in bed.
• D. Recommend raising the bed's side rails throughout the day and night.

Correct answer: A

Rationale: In this scenario, the most appropriate intervention to prevent further injury is to raise the bed's side rails when a caregiver is not present. This measure helps in preventing falls without the need for constant supervision. Choice B is not practical as continuous caregiver presence may not always be feasible. Choice C is unsafe as loose restraints can pose a strangulation risk. Choice D does not address the need for intervention when a caregiver is absent, potentially leading to an increased risk of falls.

2. A healthcare professional is reviewing the laboratory report of a child with tetralogy of Fallot that indicates an elevated RBC count. What does the professional identify as the cause of the polycythemia?

• A. Low tissue oxygen needs
• B. Tissue oxygen needs
• C. Diminished iron level
• D. Hypertrophic cardiac muscle

Correct answer: B

Rationale: The correct answer is B: Tissue oxygen needs. Polycythemia occurs as the body's response to chronic hypoxia by increasing RBC production to enhance oxygen delivery. In tetralogy of Fallot, a congenital heart defect, the heart's structure causes reduced oxygen levels in the blood. This chronic hypoxia stimulates the bone marrow to produce more red blood cells, leading to an elevated RBC count. Choice A is incorrect as low blood pressure is not directly related to polycythemia in this context. Choice C, diminished iron level, is not the cause of polycythemia in tetralogy of Fallot. Choice D, hypertrophic cardiac muscle, is not the primary cause of the elevated RBC count in this case.

3. After an infant has had corrective surgery for hypertrophic pyloric stenosis (HPS), what should the nurse teach a parent to do immediately after a feeding to limit vomiting?

• A. Rock the infant.
• B. Place the infant in an infant seat.
• C. Place the infant flat on the right side.
• D. Keep the infant awake with sensory stimulation.

Correct answer: B

Rationale: Correct Answer: B. Placing the infant in an infant seat is essential after feeding to help keep the head elevated and reduce the risk of vomiting. This position helps prevent regurgitation of formula or milk. Rocking the infant (Choice A) is incorrect because it may exacerbate vomiting due to the movement. Placing the infant flat on the right side (Choice C) is incorrect as it does not promote proper digestion and can increase the risk of vomiting. Keeping the infant awake with sensory stimulation (Choice D) is incorrect as it does not directly address the physiological need to reduce vomiting after feeding.

4. A home care nurse is visiting a family for the first time. The 4-week-old infant had surgery for exstrophy of the bladder and creation of an ileal conduit soon after birth. When the nurse arrives, the mother appears tired, and the baby is crying. After an introduction, which is the most appropriate statement by the nurse?

• A. “Tell me about your daily routine.”
• B. “You look tired. Is everything alright?”
• C. “When was the last time the baby had a bottle?”
• D. “Oh, it looks like you two are having a bad day.”

Correct answer: A

Rationale: Asking about the daily routine is the most appropriate statement by the nurse in this scenario. It allows the nurse to gather important information about the family's schedule, feeding patterns, and overall care routine for the infant. This open-ended question helps the nurse assess the family's situation comprehensively and identify any areas where support may be needed. Choices B, C, and D are less appropriate as they do not focus on gathering relevant information about the family's routine and needs but rather make assumptions or ask about specific isolated events.

5. A child with a diagnosis of pyloric stenosis is scheduled for surgery. What preoperative intervention is important for the nurse to perform?

• A. Administering intravenous fluids
• B. Monitoring for signs of infection
• C. Monitoring for signs of dehydration
• D. Monitoring for signs of pain

Correct answer: C

Rationale: The correct preoperative intervention for a child with pyloric stenosis is to monitor for signs of dehydration. Pyloric stenosis can lead to vomiting, which can result in dehydration. Monitoring for signs of dehydration is crucial to ensure the child's fluid balance is maintained. Administering intravenous fluids, although important for managing dehydration and electrolyte imbalances, would typically be done postoperatively rather than as a preoperative intervention. Monitoring for signs of infection is important but not specific to the preoperative period for pyloric stenosis. Monitoring for signs of pain is also important but may not be the most critical preoperative intervention in this scenario.

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