Nursing Elites

1. When assessing the breath sounds of an 18-month-old child who is crying, what action should the healthcare professional take?

• A. Document that the assessment is not available because the child is crying.
• B. Ask the caregiver to quiet the child so breath sounds can be auscultated.
• C. Allow the child to play with a stethoscope to distract them during auscultation.
• D. Auscultate and document breath sounds, noting that the child was crying at the time.

Correct answer: C

Rationale: Allowing the child to play with a stethoscope can help distract them, making it easier to auscultate breath sounds. This approach can create a more cooperative and engaging environment for the child, facilitating a more accurate assessment of their breath sounds. Choice A is incorrect because it does not address the need for an assessment. Choice B is not ideal as it puts pressure on the caregiver and may not be effective in calming the child. Choice D is not the best option as it does not actively involve the child in the assessment process and may not provide an accurate representation of their breath sounds.

2. A 2-year-old child with a history of frequent ear infections is brought to the clinic by the parents who are concerned about the child’s hearing. What should the nurse do first?

• A. Ask the parents about the child’s speech development
• B. Perform a hearing test
• C. Inspect the child’s ears for drainage
• D. Refer the child to an audiologist

Correct answer: C

Rationale: The most appropriate initial action for the nurse to take is to inspect the child's ears for drainage. This step can provide immediate information on the presence of infection or fluid, which could be impacting the child's hearing. By assessing for drainage, the nurse can gather valuable initial data to determine the next course of action, such as further evaluation or treatment. Asking about speech development or referring to an audiologist would be secondary steps after assessing the physical condition of the ears. Performing a hearing test would also be premature without first examining the ears for any visible issues.

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. What information should be reinforced with the parents about introducing solid foods to their infant?

• A. Begin with one tablespoon of the food.
• B. Introduce each food 4 to 7 days apart.
• C. Mix the new food with rice cereal.
• D. Remove foods when the infant refuses them.

Correct answer: B

Rationale: The correct answer is B. Introducing solid foods 4 to 7 days apart is crucial as it allows time to identify any allergic reactions or intolerances to specific foods. This gradual introduction helps parents monitor their infant's response to new foods and pinpoint any potential issues, ensuring the infant's safety and well-being. Choices A, C, and D are incorrect because starting with one tablespoon of the food, mixing new food with rice cereal, and removing foods when the infant refuses them are not recommended practices for introducing solid foods to infants.

5. A child with pertussis is receiving azithromycin (Zithromax Injection) IV. Which intervention is most important for the nurse to include in the child’s plan of care?

• A. Obtain vital signs to monitor for fluid overload
• B. Change IV site dressing every 3 days and as needed
• C. Monitor for signs of facial swelling or urticaria
• D. Assess for abdominal pain and vomiting

Correct answer: C

Rationale: Monitoring for signs of an allergic reaction, such as facial swelling or urticaria, is crucial when administering antibiotics like azithromycin. It is important to watch for these signs to promptly identify and manage any potential adverse reactions during the course of treatment.

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