Nursing Elites

1. What is important to include in discharge instructions for parents of a child who has had a tonsillectomy?

• A. Encourage the child to gargle with salt water
• B. Encourage fluid intake
• C. Provide the child with hard candy
• D. Apply heat to the neck

Correct answer: B

Rationale: Encouraging fluid intake is essential in the discharge instructions for a child who has had a tonsillectomy. It helps keep the throat moist, aids in preventing dehydration, and promotes healing. Gargling with salt water is not typically recommended after a tonsillectomy as it may irritate the surgical site. Providing the child with hard candy is not advisable as it can irritate the throat and potentially cause harm. Applying heat to the neck is also not recommended post-tonsillectomy as it can increase swelling and discomfort in the surgical area.

2. A child with a diagnosis of leukemia is receiving chemotherapy. What is the priority nursing intervention?

• A. Monitoring for signs of infection
• B. Providing nutritional support
• C. Monitoring for signs of bleeding
• D. Monitoring for signs of pain

Correct answer: A

Rationale: The priority nursing intervention for a child with leukemia receiving chemotherapy is monitoring for signs of infection. Chemotherapy can suppress the immune system, increasing the risk of infections. Detecting and managing infections promptly is crucial to prevent complications and improve outcomes. Providing nutritional support is important, but infection prevention takes precedence due to the immediate threat it poses to the child's health. Monitoring for signs of bleeding is relevant in leukemia due to decreased platelet count, but infection surveillance is more critical. Monitoring for signs of pain is essential, but addressing infections promptly is the priority to prevent further deterioration in the child's condition.

3. A child is admitted with extensive burns. The nurse notes burns on the child’s lips and singed nasal hairs. The nurse should suspect that the child has a(n)

• A. chemical burn
• B. inhalation injury
• C. electrical burn
• D. hot-water scald

Correct answer: B

Rationale: Burns on the lips and singed nasal hairs indicate inhalation injury, suggesting the child has inhaled hot gases or smoke. This presentation is common in cases where the respiratory tract is exposed to hot gases or smoke, leading to potential airway compromise. Choice A, chemical burn, is incorrect because there is no mention of exposure to chemicals, and the symptoms described are more indicative of inhalation injury. Choice C, electrical burn, is incorrect as there is no evidence of electrical involvement in the scenario provided. Choice D, hot-water scald, is incorrect because the presence of singed nasal hairs points more towards inhalation injury than a scald from hot water, emphasizing the need to prioritize airway management and respiratory support.

4. When planning the discharge of a child who had surgery for a congenital heart defect, what is an important aspect of the discharge teaching?

• A. Teaching the parents about signs of infection
• B. Providing instructions on wound care
• C. Scheduling follow-up appointments
• D. Explaining the use of prescribed medications

Correct answer: D

Rationale: Explaining the use of prescribed medications is crucial because it helps ensure proper management of the child’s condition after discharge. While teaching the parents about signs of infection and providing instructions on wound care are important aspects of postoperative care, they are not as critical as ensuring the correct understanding and administration of prescribed medications. Scheduling follow-up appointments is also important but does not directly impact the immediate post-discharge care and medication adherence.

5. A child with suspected Kawasaki disease is being assessed. What clinical manifestation is the nurse likely to observe?

• A. Generalized rash
• B. Peeling skin on the hands and feet
• C. High fever
• D. Low-grade fever

Correct answer: B

Rationale: Peeling skin on the hands and feet is a characteristic clinical manifestation of Kawasaki disease, known as desquamation. This occurs during the convalescent phase of the illness, typically around 2-3 weeks after the onset of symptoms. While a generalized rash can be present in Kawasaki disease, peeling skin on the hands and feet is a more specific and distinctive feature. High fever is also a common symptom of Kawasaki disease, usually lasting for at least 5 days, while a low-grade fever is not typically associated with this condition. Therefore, the nurse is more likely to observe peeling skin on the hands and feet in a child suspected of having Kawasaki disease, making option B the correct choice.

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