Nursing Elites

1. When explaining the occurrence of febrile seizures to a parents' class, what information should the nurse include?

• A. They may occur in minor illnesses.
• B. The cause is usually readily identified.
• C. They usually do not occur during the toddler years.
• D. The frequency of occurrence is greater in females than males.

Correct answer: A

Rationale: The correct answer is A: 'They may occur in minor illnesses.' Febrile seizures can occur even in minor illnesses, particularly in young children, and are often triggered by a rapid increase in body temperature. Choice B is incorrect because the cause of febrile seizures is not always readily identified. Choice C is incorrect as febrile seizures commonly occur in children between the ages of 6 months to 5 years, which includes the toddler years. Choice D is incorrect as febrile seizures are slightly more common in males than females.

2. How is the diagnosis of Hirschsprung disease confirmed in a 1-month-old infant admitted to the pediatric unit?

• A. Colonoscopy
• B. Rectal biopsy
• C. Multiple saline enemas
• D. Fiberoptic nasoenteric tube

Correct answer: B

Rationale: Rectal biopsy is the definitive diagnostic procedure for Hirschsprung disease in infants. It confirms the absence of ganglion cells in the affected bowel segment, which is characteristic of Hirschsprung disease. Colonoscopy (Choice A) is not typically used for confirmation as it may not provide a definitive result. Multiple saline enemas (Choice C) are utilized in the treatment of meconium ileus, a complication of cystic fibrosis, and not in the diagnosis of Hirschsprung disease. Fiberoptic nasoenteric tube (Choice D) is not a diagnostic tool for Hirschsprung disease; it is commonly used for gastrointestinal decompression or feeding purposes but does not confirm the diagnosis.

3. At 7 AM, a healthcare professional receives the information that an adolescent with diabetes has a 6:30 AM fasting blood glucose level of 180 mg/dL. What is the priority nursing action at this time?

• A. Encourage the adolescent to start exercising.
• B. Ask the adolescent to obtain an immediate glucometer reading.
• C. Inform the adolescent that a complex carbohydrate such as cheese should be eaten.
• D. Tell the adolescent that the prescribed dose of rapid-acting insulin should be administered.

Correct answer: D

Rationale: The correct priority nursing action in this situation is to administer the prescribed dose of rapid-acting insulin. Rapid-acting insulin is necessary to help lower the elevated blood glucose level quickly, thereby preventing potential complications of hyperglycemia. Encouraging exercise, obtaining a glucometer reading, or suggesting consumption of complex carbohydrates like cheese may not address the immediate need to bring down the high blood glucose level effectively. Exercise could potentially raise blood glucose levels, obtaining a glucometer reading may delay necessary treatment, and consuming complex carbohydrates can further elevate blood glucose levels in this scenario.

4. The parents of a child who is scheduled for open-heart surgery ask why their child must be subjected to chest tubes after surgery. What should the nurse consider before responding in language the parents will understand?

• A. They will increase tidal volumes.
• B. Drainage of air and fluid will be facilitated.
• C. They will maintain positive intrapleural pressure.
• D. Pressure on the pericardium and chest wall will be regulated.

Correct answer: B

Rationale: Chest tubes are used to drain air and fluid from the chest cavity to prevent complications such as pneumothorax or cardiac tamponade after surgery. Choice A is incorrect as chest tubes are not used to increase tidal volumes. Choice C is incorrect as chest tubes do not maintain positive intrapleural pressure; instead, they assist in removing excess air or fluid. Choice D is incorrect as chest tubes do not regulate pressure on the pericardium and chest wall; they primarily aid in drainage.

5. A child has been diagnosed with classic hemophilia. A nurse teaches the child’s parents how to administer the plasma component factor VIII through a venous port. It is to be given 3 times a week. What should the nurse tell them about when to administer this therapy?

• A. Whenever a bleed is suspected
• B. In the morning on scheduled days
• C. At bedtime while the child is lying quietly in bed
• D. On a regular schedule at the parents’ convenience

Correct answer: B

Rationale: Administering factor VIII in the morning on scheduled days ensures that there is a consistent level of the plasma component throughout the day, especially when the child is active. This timing helps to maintain adequate levels of factor VIII to prevent bleeding episodes. Choice A is incorrect because administering factor VIII only when a bleed is suspected would not provide the consistent prophylactic coverage needed for children with hemophilia. Choice C is incorrect as bedtime administration may not be practical for ensuring the plasma component is available during the child's active hours. Choice D is incorrect because administering factor VIII on a regular schedule, rather than at specific times of the day, may not optimize its effectiveness in preventing bleeding episodes.

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