Nursing Elites

1. What is an important nursing responsibility when a dysrhythmia is suspected?

• A. order an immediate electrocardiogram
• B. count the radial pulse every 1 minute for five times
• C. count the apical pulse for 1 full minute, and compare the rate with the radial pulse rate
• D. have someone else take the radial pulse simultaneously with the apical pulse

Correct answer: C

Rationale: When a dysrhythmia is suspected, an important nursing responsibility is to count the apical pulse for 1 full minute and then compare this rate with the radial pulse rate. This method helps in identifying dysrhythmias as it allows for a direct comparison of the heart's rhythm at two different pulse points. Ordering an immediate electrocardiogram (Choice A) may be necessary but should not be the first step. Counting the radial pulse multiple times (Choice B) is not as accurate as comparing rates directly. Having someone else take the radial pulse simultaneously (Choice D) may introduce errors and inconsistencies in the measurement.

2. A child is brought to the clinic after tripping over a rock. The child states, 'I twisted my ankle,' and is given a diagnosis of a sprain. What intervention is most important for the nurse to include in the discharge instructions for this child?

• A. For the first 24 hours, apply ice for 20 minutes and remove for 60 minutes.
• B. Bed rest with the leg elevated for 36 hours.
• C. May take an NSAID for pain as prescribed.
• D. Use a compression dressing for 72 hours.

Correct answer: A

Rationale: The correct answer is A. Applying ice in intervals helps to reduce swelling and pain in the first 24 hours after a sprain. This intervention is crucial in the initial management of a sprain to decrease inflammation and provide pain relief. Bed rest with the leg elevated for 36 hours (Choice B) is not recommended as prolonged immobilization can lead to stiffness and decreased range of motion. Allowing the child to take an NSAID for pain as prescribed (Choice C) is a supportive measure but not as essential as ice application in the acute phase. Using a compression dressing for 72 hours (Choice D) may assist in reducing swelling, but it is not as critical as the immediate application of ice to manage pain and inflammation effectively.

3. At 0345, you receive a call for a woman in labor. Upon arriving at the scene, you are greeted by a very anxious man who tells you that his wife is having her baby 'now.' This man escorts you into the living room where a 25-year-old woman is lying on the couch in obvious pain. After determining that delivery is not imminent, you begin transport. While en route, the mother tells you that she feels the urge to push. You assess her and see the top of the baby's head bulging from the vagina. What is your most appropriate first action?

• A. allow the head to deliver and check for the location of the cord
• B. advise your partner to stop the ambulance and assist with the delivery
• C. tell the mother to take short, quick breaths until you arrive at the hospital
• D. prepare the mother for an emergency delivery and open the obstetrics kit

Correct answer: B

Rationale: The correct action in this scenario is to advise your partner to stop the ambulance and assist with the delivery. When the mother feels the urge to push and you see the baby's head bulging from the vagina, it indicates an imminent delivery. Stopping the ambulance allows for a safer environment for the delivery of the baby and ensures that immediate assistance can be provided to both the mother and the newborn. Allowing the head to deliver before checking for the cord (Choice A) may delay necessary interventions in case of complications. Instructing the mother to take short, quick breaths (Choice C) is not appropriate when the baby's head is already visible. Preparing for an emergency delivery and opening the obstetrics kit (Choice D) is important but should come after stopping the ambulance and assisting with the imminent birth.

4. The healthcare professional is assessing a 4-year-old client. Which finding suggests to the healthcare professional this child may have a genetic disorder?

• A. Inquiry reveals the child had feeding problems.
• B. The child weighs 40 lb (18.2 kg) and is 40 in (101.6 cm) in height.
• C. The child has low-set ears with lobe creases.
• D. The child can hop on one foot but cannot skip.

Correct answer: C

Rationale: Low-set ears with lobe creases are often associated with genetic disorders and can indicate underlying chromosomal abnormalities. This physical characteristic is known to be a common sign in various syndromes like Down syndrome. Choices A, B, and D are not directly linked to genetic disorders. Feeding problems and specific weight/height measurements are more general indicators of growth and development, while the ability to hop on one foot but not skip is a developmental milestone assessment that does not specifically point towards a genetic disorder.

5. Which of the following parameters would be LEAST reliable when assessing the perfusion status of a 2-year-old child with possible shock?

• A. distal capillary refill
• B. systolic blood pressure
• C. skin color and temperature
• D. presence of peripheral pulses

Correct answer: B

Rationale: Systolic blood pressure is the least reliable parameter when assessing the perfusion status of a 2-year-old child with possible shock. In pediatric patients, especially young children, blood pressure may not decrease until significant shock has already occurred, making it a late indicator of inadequate perfusion. Depending solely on systolic blood pressure to evaluate perfusion status in this age group can lead to a delay in appropriate interventions. Distal capillary refill time, skin color, and temperature changes, and the presence of peripheral pulses are more sensitive and early indicators of perfusion status in pediatric patients. Monitoring distal capillary refill provides information on peripheral perfusion, while changes in skin color and temperature can signal circulatory compromise. Evaluating the presence or absence of peripheral pulses offers insights into vascular perfusion. These parameters offer more reliable and prompt feedback on a child's perfusion status compared to systolic blood pressure.

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