Nursing Elites

1. After observing a mother giving her 11-month-old ferrous sulfate followed by two ounces of orange juice, what should the nurse do next?

• A. Suggest placing the iron drops in the orange juice and feed the infant.
• B. Tell the mother to follow the iron drops with formula instead of orange juice.
• C. Instruct the mother to feed the infant nothing in the next 30 minutes after the iron.
• D. Give positive feedback about the way she administered the sulfate.

Correct answer: D

Rationale: Providing positive feedback to the mother for correctly administering the iron supplements is essential as it reinforces proper medication administration practices. This encouragement can help build the mother's confidence and ensure that she continues to administer the supplements correctly in the future, promoting the infant's health and well-being. Choices A, B, and C are incorrect because there is no need to suggest altering the administration method, changing the liquid used, or restricting feeding immediately after administering the iron supplement. Giving positive feedback is the most appropriate action in this scenario to acknowledge the mother's correct administration technique.

2. A 2-year-old child with heart failure (HF) is admitted for replacement of a graft for coarctation of the aorta. Prior to administering the next dose of digoxin (Lanoxin), the nurse obtains an apical heart rate of 128 bpm. What action should the nurse take?

• A. Determine the pulse deficit.
• B. Administer the scheduled dose.
• C. Calculate the safe dose range.
• D. Review the serum digoxin level.

Correct answer: B

Rationale: Administering the scheduled dose is appropriate in this scenario since the heart rate of 128 bpm is within an acceptable range for a 2-year-old child with heart failure. Monitoring for signs of digoxin toxicity is important; however, the immediate action required is to administer the scheduled dose as prescribed based on the heart rate assessment.

3. What recommendation should the PN provide to help a 5-year-old girl who has started wetting the bed again after being dry at night for several months?

• A. Explain that bedwetting is normal in children and will pass with time.
• B. Advise limiting fluids in the evening and before bedtime.
• C. Suggest punishing the child for wetting the bed to prevent recurrence.
• D. Encourage the child to use the bathroom immediately before bed.

Correct answer: D

Rationale: Encouraging the child to use the bathroom before bed is a helpful recommendation to prevent nighttime bedwetting. Bedwetting can sometimes reoccur due to stress or other factors, and ensuring the child empties their bladder before sleeping may reduce the likelihood of bedwetting episodes. Choice A is incorrect because while bedwetting is common in children, it is essential to provide practical solutions rather than just reassurance. Choice B is not the best option for a child who has recently started bedwetting again after being dry, as it may not address the underlying cause. Choice C is inappropriate and harmful as punishing the child for bedwetting can lead to psychological distress and worsen the situation.

4. An 8-year-old male client with nephrotic syndrome is receiving salt-poor human albumin IV. Which findings indicate to the nurse that the child is manifesting a therapeutic response?

• A. Decreased urinary output
• B. Decreased periorbital edema
• C. Increased periods of rest
• D. Weight gain of 0.5 kg/day

Correct answer: B

Rationale: In nephrotic syndrome treatment, decreased periorbital edema is a positive therapeutic response as it indicates a reduction in fluid retention. Periorbital edema is a common symptom of nephrotic syndrome due to fluid accumulation, so a decrease in this swelling signifies an improvement in the condition.

5. 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.

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