Nursing Elites

1. What clinical manifestation of tetralogy of Fallot should the nurse expect when caring for children with this diagnosis?

• A. Slow respirations
• B. Clubbing of fingers
• C. Decreased RBC counts
• D. Subcutaneous hemorrhages

Correct answer: B

Rationale: The correct answer is B: Clubbing of fingers. Clubbing of fingers is a common manifestation in children with tetralogy of Fallot due to chronic hypoxia. This condition causes the fingertips and nails to enlarge, creating a bulbous or club-like appearance. Slow respirations (Choice A) are not a typical clinical manifestation of tetralogy of Fallot. Decreased RBC counts (Choice C) may be seen in conditions like anemia but are not specific to tetralogy of Fallot. Subcutaneous hemorrhages (Choice D) are not a characteristic clinical manifestation of tetralogy of Fallot.

2. While caring for a 5-year-old child hospitalized for the treatment of acute lymphoblastic leukemia (ALL), what is the priority nursing intervention?

• A. Administering antibiotics
• B. Preventing infection
• C. Providing nutritional support
• D. Managing pain

Correct answer: B

Rationale: The priority nursing intervention for a child with acute lymphoblastic leukemia (ALL) is preventing infection due to their compromised immune system. Children undergoing treatment for ALL are highly susceptible to infections, making infection prevention crucial for the child's well-being and treatment success. Administering antibiotics, though important in specific cases, is not the priority in this scenario. Providing nutritional support and managing pain are significant aspects of care but take a back seat to infection prevention in this situation.

3. A premature infant with respiratory distress syndrome (RDS) receives artificial surfactant. How does the nurse explain surfactant therapy to the parents?

• A. Surfactant improves the ability of your baby’s lungs to exchange oxygen and carbon dioxide.
• B. The drug prevents your baby from requiring excessive sedation.
• C. Surfactant is used to reduce episodes of periodic apnea.
• D. Your baby needs this medication to combat a potential respiratory tract infection.

Correct answer: A

Rationale: The correct answer is A. Surfactant therapy is explained to parents as a treatment that enhances the lungs' ability to exchange oxygen and carbon dioxide. This is essential for premature infants with respiratory distress syndrome (RDS) as it helps improve their respiratory function. Choices B, C, and D are incorrect because surfactant therapy primarily focuses on addressing lung function and is not related to sedation, apnea reduction, or fighting respiratory tract infections.

4. A child with a diagnosis of pyloric stenosis is scheduled for surgery. What preoperative intervention is important for the nurse to perform?

• A. Administering intravenous fluids
• B. Monitoring for signs of infection
• C. Monitoring for signs of dehydration
• D. Monitoring for signs of pain

Correct answer: C

Rationale: The correct preoperative intervention for a child with pyloric stenosis is to monitor for signs of dehydration. Pyloric stenosis involves the obstruction of the pyloric sphincter, leading to projectile vomiting, which can result in dehydration and electrolyte imbalances. Monitoring for signs of dehydration is crucial to assess the child's fluid status and prevent complications. Administering intravenous fluids, although important in managing dehydration, is not typically a preoperative intervention but rather a treatment during or after surgery. Monitoring for signs of infection and pain may also be important but are not the priority preoperative interventions in a child with pyloric stenosis.

5. After surgery to correct hypertrophic pyloric stenosis (HPS) in a 3-week-old infant who had been formula-fed, which postoperative feeding order is appropriate?

• A. Thickened formula 24 hours after surgery
• B. Withholding feedings for the first 24 hours
• C. Regular formula feeding within 24 hours after surgery
• D. Additional glucose feedings as desired after the first 24 hours

Correct answer: C

Rationale: Following surgery for hypertrophic pyloric stenosis (HPS) in infants, it is appropriate to resume regular formula feeding within 24 hours postoperatively to support recovery. This helps maintain adequate nutrition and hydration for the infant. Choice A is incorrect because thickened formula may not be necessary and could potentially cause issues postoperatively. Choice B is incorrect as withholding feedings for the first 24 hours can lead to nutritional deficiencies and delay recovery. Choice D is inappropriate as additional glucose feedings are not typically indicated postoperatively for infants with HPS and may not provide the necessary nutrition needed for recovery.

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