Nursing Elites

1. What is the priority assessment for a nurse when caring for an infant suspected of having necrotizing enterocolitis (NEC)?

• A. Hold feedings.
• B. Check gastric residuals before feedings.
• C. Take rectal temperature.
• D. Closely monitor abdominal distention.

Correct answer: D

Rationale: The correct answer is D: Closely monitor abdominal distention. Monitoring the abdomen for signs of distention is crucial in the early detection of necrotizing enterocolitis (NEC). In NEC, the bowel wall is edematous and breaking down, leading to abdominal distention. Holding feedings is important in the management of NEC, as feedings may need to be stopped temporarily. Checking gastric residuals before feedings helps in assessing the infant's tolerance to feedings. Taking rectal temperatures is contraindicated in NEC as it can lead to the perforation of the bowel.

2. What is the therapeutic intervention that provides the best chance of survival for a child with cirrhosis?

• A. Nutritional support
• B. Liver transplantation
• C. Blood component therapy
• D. Treatment with corticosteroids

Correct answer: B

Rationale: Liver transplantation offers the best chance of survival for children with cirrhosis, especially in advanced stages where the liver can no longer function effectively. Cirrhosis is a late stage of scarring of the liver caused by many forms of liver diseases and conditions, such as hepatitis and chronic alcoholism. While nutritional support, blood component therapy, and corticosteroids may be part of the treatment plan to manage symptoms and complications, they do not address the underlying cause of cirrhosis or provide a cure like liver transplantation does.

3. The parent of a 1-month-old infant voices concern about the infant’s respirations. The parent states the respirations are rapid and irregular. Which information should the nurse provide?

• A. The normal respiratory rate for an infant at this age is between 20 and 30 breaths per minute.
• B. The respirations of a 1-month-old infant are normally irregular and periodically pause.
• C. An infant at this age should have regular respirations.
• D. The irregularity of the infant's respirations is concerning; I will notify the health care provider.

Correct answer: B

Rationale: The correct answer is B. Irregular respirations with periodic pauses are normal in a 1-month-old infant. Choice A is incorrect because the normal respiratory rate for an infant at this age is higher than the range provided. Choice C is incorrect as irregular respirations are expected in infants. Choice D is not appropriate as irregular respirations with periodic pauses are a normal finding in young infants and do not necessarily indicate a concern that requires immediate notification of the healthcare provider.

4. A new parent, when asked by a nurse, explains that the 4-month-old infant has been nursing regularly every 3 to 4 hours and seems satisfied. However, the parent recently introduced solid food in the form of unbuttered popcorn to the infant as a supplement. What should be the primary nursing concern in this situation?

• A. Imbalanced nutrition, more than body requirements, related to introduction of a high-calorie food
• B. Risk for aspiration related to feeding the infant an inappropriate food
• C. Imbalanced nutrition, less than body requirements, related to introduction of a low-nutritive food
• D. Readiness for enhanced nutrition, related to the age of the infant

Correct answer: B

Rationale: The primary nursing concern in this situation is the risk for aspiration. Popcorn is a choking hazard for infants, as their airway is not fully developed to handle solid foods like popcorn. Choices A, C, and D are incorrect because the main focus should be on the immediate risk of aspiration due to the inappropriate solid food given to the infant, rather than on nutritional imbalances or readiness for enhanced nutrition.

5. What type of shock is characterized by a hypersensitivity reaction causing massive vasodilation and capillary leaks, which may occur with drug or latex allergy?

• A. Neurogenic shock
• B. Cardiogenic shock
• C. Hypovolemic shock
• D. Anaphylactic shock

Correct answer: D

Rationale: Anaphylactic shock is a severe allergic reaction that causes massive vasodilation and increased capillary permeability, leading to rapid fluid shifts and circulatory collapse if not treated promptly. Neurogenic, cardiogenic, and hypovolemic shocks have different etiologies.

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