Nursing Elites

1. The nurse is caring for a 14-year-old adolescent who was admitted to the hospital after a suicide attempt. The adolescent’s mood appears stable, and the healthcare provider has recommended discharge. What is the nurse’s priority action?

• A. Ensure that a safety plan is in place before discharge
• B. Provide education about medication adherence
• C. Encourage the adolescent to participate in group therapy
• D. Schedule a follow-up appointment with a mental health professional

Correct answer: A

Rationale: The priority action for the nurse is to ensure that a safety plan is in place before discharge. A safety plan is essential to assist the adolescent in managing future crises and decreasing the likelihood of another suicide attempt. It provides guidance on coping strategies and resources to help the adolescent stay safe in times of distress.

2. Following a motor vehicle collision, a 3-year-old girl has a spica cast applied. Which toy is best for the nurse to offer this child?

• A. Duck that squeaks.
• B. Fashion doll and clothes.
• C. Set of cloth and hand puppets.
• D. Handheld video game.

Correct answer: C

Rationale: In this scenario, a set of cloth and hand puppets is the best choice for a 3-year-old with a spica cast. Hand puppets encourage imaginative play, creativity, and interaction, which are developmentally appropriate for a child of this age. The soft materials are safe for the child and can provide entertainment and engagement without posing a risk of injury. The other options, such as a duck that squeaks, a fashion doll and clothes, and a handheld video game, may not be as suitable for a child in a spica cast due to safety concerns, lack of interactive play, or developmental appropriateness.

3. The healthcare provider finds a 6-month-old infant unresponsive and calls for help. After opening the airway and finding the infant is still not breathing, which action should the provider take?

• A. Palpate femoral pulse and check for regularity.
• B. Deliver cycles of 30 chest compressions and 2 breaths.
• C. Give two breaths that make the chest rise.
• D. Feel the carotid pulse and check for adequate breathing.

Correct answer: C

Rationale: In pediatric basic life support, for an unresponsive infant who is not breathing normally, the correct action is to give two breaths that make the chest rise. This helps provide oxygen to the infant's body and is a crucial step in resuscitation efforts for infants in distress. Choices A, B, and D are incorrect. Palpating the femoral pulse or feeling the carotid pulse is not indicated in this scenario where the infant is unresponsive and not breathing. Delivering cycles of chest compressions and breaths is not the immediate action to take; the priority is to provide two breaths to help with oxygenation.

4. A 7-year-old child with a history of asthma presents to the clinic with shortness of breath and wheezing. The nurse notes that the child’s peak flow reading is in the red zone. What should the nurse do first?

• A. Administer a bronchodilator
• B. Reassess the peak flow reading
• C. Notify the healthcare provider
• D. Provide oxygen therapy

Correct answer: A

Rationale: When a child with asthma presents with shortness of breath and wheezing, and the peak flow reading is in the red zone, indicating severe airflow limitation, the priority intervention is to administer a bronchodilator. Bronchodilators help dilate the airways quickly, improving airflow and assisting with breathing. Reassessing the peak flow reading is important but not the first action to take in a severe asthma exacerbation. Notifying the healthcare provider can be done after initiating immediate treatment with a bronchodilator. Providing oxygen therapy may be needed in some cases, but addressing the airway constriction with a bronchodilator should come first to improve ventilation.

5. A 7-year-old child with cystic fibrosis is admitted to the hospital with a respiratory infection. The nurse is teaching the child’s parents about the importance of chest physiotherapy (CPT). Which statement by the parents indicates they need further teaching?

• A. We should perform CPT before meals.
• B. CPT will help loosen mucus in the lungs.
• C. We should perform CPT right after the child eats.
• D. CPT is an important part of our child’s treatment.

Correct answer: C

Rationale: The correct answer is C. Chest physiotherapy should not be performed right after meals to avoid inducing vomiting. It should be done before meals or at least 1 hour after for effective mucus clearance and to prevent any potential complications like vomiting. Choice A is correct as performing CPT before meals helps in loosening mucus. Choice B is also correct as CPT is indeed helpful in loosening mucus in the lungs. Choice D is correct as CPT plays a crucial role in the treatment of cystic fibrosis.

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