Nursing Elites

1. The parents of a 2-month-old infant, who is being discharged after treatment for pyloric stenosis, are being educated by the healthcare provider. Which statement by the parents indicates a need for further teaching?

• A. We should feed our baby in an upright position
• B. We should avoid feeding our baby solid foods until at least 6 months of age
• C. We will lay our baby on their stomach to sleep
• D. We will burp our baby frequently during feedings

Correct answer: C

Rationale: The correct answer is C. Placing babies on their stomach to sleep increases the risk of sudden infant death syndrome (SIDS). The safest sleep position for infants is on their back to reduce the risk of SIDS. Teaching parents about safe sleep practices is crucial in preventing potential harm to the infant. Choices A, B, and D are all correct statements that promote the well-being of the infant. Feeding the baby in an upright position helps prevent reflux, delaying solid foods until 6 months of age is recommended for proper growth and development, and burping the baby frequently during feedings helps prevent gas buildup and colic.

2. The healthcare provider is preparing to administer a scheduled dose of digoxin to a 4-year-old child with heart failure. The healthcare provider notes that the child’s heart rate is 70 beats per minute. What should the healthcare provider do next?

• A. Administer the medication as prescribed
• B. Hold the medication and notify the healthcare provider
• C. Recheck the heart rate in 30 minutes
• D. Administer half of the prescribed dose

Correct answer: B

Rationale: In pediatric patients, digoxin administration is guided by the heart rate. If the child's heart rate is below the established threshold, which is typically 90-100 beats per minute in a 4-year-old, the medication should be withheld, and the healthcare provider should be notified for further evaluation and instructions. Choice A is incorrect because administering the medication when the heart rate is low can lead to adverse effects. Rechecking the heart rate in 30 minutes (Choice C) may delay necessary intervention if the heart rate remains low. Administering half of the prescribed dose (Choice D) is not recommended without healthcare provider guidance.

3. The mother of a 9-month-old girl provides the practical nurse with information about her daughter's diet. Which statement by the mother may indicate why the infant has been diagnosed with iron-deficiency anemia?

• A. She almost never drinks sugary water.
• B. She has been on whole milk for 7 months.
• C. She likes to chew on bread as a snack.
• D. She doesn't like to eat peaches or pears.

Correct answer: B

Rationale: The correct answer is B. Infants should not be given cow's milk before 1 year of age as it can interfere with iron absorption and lead to anemia. Choice A is incorrect as avoiding sugary water is actually a good practice. Choice C is unrelated to iron-deficiency anemia. Choice D, not liking peaches or pears, is also not directly related to iron-deficiency anemia.

4. A 16-year-old adolescent is admitted to the hospital with a diagnosis of meningitis. The nurse notes that the client has a severe headache and photophobia. What is the nurse’s priority action?

• A. Administer prescribed pain medication
• B. Place the client in a dark, quiet room
• C. Notify the healthcare provider
• D. Encourage the client to rest

Correct answer: B

Rationale: The priority action for the nurse when a client with meningitis presents with a severe headache and photophobia is to place the client in a dark, quiet room. This intervention helps reduce stimuli that can exacerbate symptoms such as headache and photophobia. Creating a calm environment can provide relief and promote comfort for the client while also supporting their recovery. Administering pain medication may be necessary but ensuring a suitable environment takes precedence. Notifying the healthcare provider is important but is not the immediate priority. Encouraging rest is beneficial, but creating an appropriate environment to alleviate symptoms is the initial essential step.

5. A 3-year-old child with a high fever and sore throat is brought to the clinic. The nurse observes that the child is drooling and has difficulty swallowing. What is the nurse’s priority action?

• A. Administer antipyretic medication
• B. Prepare for emergency airway management
• C. Offer the child ice chips to suck on
• D. Assess the child’s hydration status

Correct answer: B

Rationale: In a 3-year-old child with drooling, difficulty swallowing, high fever, and sore throat, the nurse should prioritize preparing for emergency airway management. These signs may indicate epiglottitis, a condition that can quickly obstruct the airway, leading to respiratory distress and potentially fatal outcomes if not managed promptly. Administering antipyretic medication (Choice A) may be necessary later but is not the priority. Offering ice chips (Choice C) is contraindicated as the child has difficulty swallowing. Assessing hydration status (Choice D) is important but not the priority when the airway is at risk.

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