Nursing Elites

1. The nurse is preparing to admit a child to the hospital with a diagnosis of acute poststreptococcal glomerulonephritis. The nurse understands that the peak age at onset for this disease is what?

• A. 2 to 4 years
• B. 5 to 7 years
• C. 8 to 10 years
• D. 11 to 13 years

Correct answer: B

Rationale: The peak age for the onset of acute poststreptococcal glomerulonephritis is typically between 5 and 7 years old. This age group is most affected due to the higher incidence of streptococcal infections in school-aged children, which can lead to this renal complication.

2. The nurse is taking vital signs on a group of assigned preschool-aged children. Which assessment finding would indicate the need for further action?

• A. Respiratory rate of 20 breaths per minute
• B. Heart rate of 89 beats per minute
• C. Heart rate of 120 beats per minute
• D. Respiratory rate of 24 breaths per minute

Correct answer: C

Rationale: A heart rate of 120 beats per minute is high for a preschool-aged child and may indicate an underlying issue that requires further assessment. A respiratory rate of 20 breaths per minute (choice A) is within the normal range for preschool children. Similarly, a heart rate of 89 beats per minute (choice B) falls within the expected range. A respiratory rate of 24 breaths per minute (choice D) is slightly elevated but may not be as concerning as a heart rate of 120 beats per minute.

3. What is a primary consideration for complications when planning nursing care for an infant with Meconium aspiration syndrome?

• A. Hypoglycemia
• B. Bowel obstruction
• C. Airway obstruction
• D. Carbon dioxide retention

Correct answer: C

Rationale: The correct answer is C: Airway obstruction. When planning nursing care for an infant with Meconium aspiration syndrome, a primary consideration for complications is the potential of airway obstruction. After the passage of meconium into the amniotic fluid, the infant may inhale or swallow the fluid, leading to meconium aspiration into the lower airways and causing a partial airway obstruction. This can result in respiratory distress and hypoxemia. Hypoglycemia (choice A) is a metabolic condition unrelated to meconium aspiration. Bowel obstruction (choice B) with meconium may indicate other conditions like cystic fibrosis or Hirschsprung disease, not directly related to meconium aspiration syndrome. Carbon dioxide retention (choice D) is not a primary consideration in meconium aspiration syndrome; instead, the focus is on addressing the airway obstruction and potential respiratory compromise.

4. In the newborn, into what muscle is intramuscular vitamin K administered?

• A. Deltoid
• B. Dorsogluteal
• C. Rectus femoris
• D. Vastus lateralis

Correct answer: D

Rationale: In newborns, intramuscular vitamin K is traditionally administered into the vastus lateralis muscle. This site is preferred due to its large muscle mass and accessibility. The dorsogluteal site is not recommended for newborns due to the risk of injury to the sciatic nerve. The deltoid site is also not recommended for newborns. The rectus femoris muscle is not commonly used for intramuscular injections in newborns.

5. The nurse is preparing to give acetaminophen (Tylenol) to a child who has a fever. What nursing action is appropriate?

• A. Retake the temperature in 15 minutes after giving the Tylenol.
• B. Place a warm blanket on the child so chilling does not occur.
• C. Check to be sure the Tylenol dose does not exceed 15 mg/kg.
• D. Use cold compresses instead of Tylenol to control the fever.

Correct answer: C

Rationale: Ensuring the dose does not exceed 15 mg/kg is critical to avoid overdose and potential liver damage. Retaking the temperature immediately or using cold compresses is not necessary, and placing a warm blanket could exacerbate the fever.

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