Nursing Elites

1. What information should be included in the preoperative plan of care for an infant with myelomeningocele?

• A. Positioning the infant supine with a pillow under the buttocks
• B. Covering the sac with saline-soaked nonadhesive gauze
• C. Wrapping the infant snugly in a blanket
• D. Applying a diaper to prevent fecal soiling of the sac

Correct answer: B

Rationale: Covering the sac with saline-soaked nonadhesive gauze is essential in the preoperative care of an infant with myelomeningocele. This practice helps prevent infection and maintains moisture around the sac before surgery, promoting optimal healing outcomes. Positioning the infant supine with a pillow under the buttocks may be uncomfortable and unnecessary. Wrapping the infant snugly in a blanket does not address the specific care needs of the myelomeningocele. Applying a diaper over the sac can increase the risk of infection and should be avoided in this case.

2. A healthcare professional is reviewing the laboratory report of a child with tetralogy of Fallot that indicates an elevated RBC count. What does the professional identify as the cause of the polycythemia?

• A. Low tissue oxygen needs
• B. Tissue oxygen needs
• C. Diminished iron level
• D. Hypertrophic cardiac muscle

Correct answer: B

Rationale: The correct answer is B: Tissue oxygen needs. Polycythemia occurs as the body's response to chronic hypoxia by increasing RBC production to enhance oxygen delivery. In tetralogy of Fallot, a congenital heart defect, the heart's structure causes reduced oxygen levels in the blood. This chronic hypoxia stimulates the bone marrow to produce more red blood cells, leading to an elevated RBC count. Choice A is incorrect as low blood pressure is not directly related to polycythemia in this context. Choice C, diminished iron level, is not the cause of polycythemia in tetralogy of Fallot. Choice D, hypertrophic cardiac muscle, is not the primary cause of the elevated RBC count in this case.

3. When caring for a child and family who just moved out of a dangerous neighborhood, which of the following approaches is appropriate to the family stress theory?

• A. Determining who the decision maker is
• B. Assessing the child's coping abilities
• C. Finding out how siblings feel
• D. Explaining procedures to siblings

Correct answer: B

Rationale: Assessing the child's coping abilities is appropriate when applying the family stress theory because it helps understand how well the child is managing the stress of the situation. This assessment can provide insights into the child's emotional well-being and resilience, enabling healthcare providers to offer appropriate support. Choices A, C, and D are less relevant in the context of family stress theory. Determining who the decision-maker is may be important but is not directly related to assessing the child's coping abilities. Finding out how siblings feel and explaining procedures to siblings may be valuable aspects of care but are not specifically aligned with the core principles of the family stress theory, which focus on understanding and addressing stress within the family unit.

4. A 6-year-old child with asthma is admitted to the hospital with an acute exacerbation. What is the priority nursing intervention?

• A. Administering a bronchodilator
• B. Administering an antihistamine
• C. Administering a corticosteroid
• D. Administering oxygen

Correct answer: A

Rationale: Administering a bronchodilator is the priority intervention for a child experiencing an acute asthma exacerbation. Bronchodilators help to dilate the airways, making breathing easier and relieving acute symptoms of asthma. Antihistamines are not the first-line treatment for asthma exacerbations; they are more commonly used for allergic reactions. Corticosteroids are beneficial in reducing inflammation in asthma but are usually administered after bronchodilators to provide long-term control. Oxygen therapy may be necessary in severe cases of asthma exacerbation, but bronchodilators take precedence in improving airway patency and respiratory distress.

5. A child with a diagnosis of celiac disease is admitted to the hospital. What dietary restriction should the nurse teach the parents?

• A. Avoid dairy products
• B. Avoid gluten
• C. Avoid high-fat foods
• D. Avoid foods high in sugar

Correct answer: B

Rationale: The correct answer is to 'Avoid gluten.' Celiac disease is an autoimmune disorder triggered by the consumption of gluten, a protein found in wheat, barley, and rye. When individuals with celiac disease ingest gluten, it causes an immune response that attacks the lining of the small intestine. Therefore, avoiding gluten is crucial in managing celiac disease to prevent symptoms and intestinal damage. Choices A, C, and D are incorrect because they do not address the specific dietary restriction necessary for individuals with celiac disease. While some individuals with celiac disease may also have lactose intolerance (not dairy allergy) or may need to manage fat or sugar intake for other health reasons, the primary dietary focus for celiac disease is the strict avoidance of gluten-containing foods.

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