Nursing Elites

1. The nurse is assessing a postpartum client's fundus. Where should the nurse expect to find the fundus 24 hours after delivery?

• A. At the level of the umbilicus
• B. 1 cm above the symphysis pubis
• C. At the level of the xiphoid process
• D. 2 cm below the umbilicus

Correct answer: A

Rationale: After delivery, the fundus is expected to be at the level of the umbilicus 24 hours postpartum. This position indicates that the uterus is involuting properly. Assessing the fundal height helps monitor the progress of uterine involution and can identify any potential complications like postpartum hemorrhage.

2. To prevent diarrhea in children, a vaccine is available against which of the following?

• A. Adenovirus
• B. Rotavirus
• C. Enterovirus
• D. All of the above

Correct answer: B

Rationale: The correct answer is B - Rotavirus. Rotavirus vaccine is available to prevent diarrhea in children. Rotavirus is a common cause of severe diarrhea in infants and young children globally, and vaccination has been shown to be effective in reducing the burden of this disease. Choices A and C are incorrect because there is no specific vaccine available for Adenovirus or Enterovirus to prevent diarrhea in children. Choice D is incorrect because while vaccines are available for some viruses that can cause diarrhea in children, not all mentioned in the choices have a specific vaccine available.

3. Beta-adrenergic agonists such as albuterol are given to Reggie, a child with asthma, to primarily do which of the following?

• A. Dilate the bronchioles
• B. Reduce secondary infections
• C. Decrease postnasal drip
• D. Reduce airway inflammation

Correct answer: A

Rationale: Beta-adrenergic agonists like albuterol are bronchodilators that primarily work by relaxing and dilating the bronchioles, which helps to alleviate bronchoconstriction, a characteristic feature of asthma. This action leads to improved airflow and easier breathing for individuals experiencing asthma symptoms.

4. Which of the following signs would you expect to see in a child with respiratory failure?

• A. Slow, irregular breathing
• B. Flushed skin
• C. Strong cry
• D. Unconsciousness

Correct answer: A

Rationale: In a child with respiratory failure, slow, irregular breathing is a common sign. Respiratory failure impairs the ability to exchange oxygen and carbon dioxide efficiently, leading to altered breathing patterns. Flushed skin, a strong cry, or unconsciousness may not be specific signs of respiratory failure and could be indicative of other conditions. Flushed skin may be a sign of fever or increased blood flow, a strong cry may indicate pain or distress, and unconsciousness can have various causes beyond respiratory failure.

5. A female child, age 2, is brought to the emergency department after ingesting an unknown number of aspirin tablets about 30 minutes earlier. Her father is blaming the mother for neglecting the child while she was cooking. On entering the examination room, the child is crying and clinging to the mother. Which data should the nurse obtain first?

• A. Heart rate, respiratory rate, and blood pressure
• B. Recent exposure to communicable diseases
• C. Number of immunizations received
• D. Height and weight

Correct answer: A

Rationale: In this scenario, the priority is to assess the child's vital signs first, including heart rate, respiratory rate, and blood pressure. These data will provide critical information on the child's current physiological status and guide further interventions. Option B, recent exposure to communicable diseases, is not the priority in an acute ingestion situation. Option C, number of immunizations received, and option D, height and weight, are important but not as critical as assessing vital signs in this immediate situation.

Similar Questions