Nursing Elites

1. Which artery should you palpate when assessing for a pulse in an unresponsive 6-month-old patient?

• A. Radial
• B. Brachial
• C. Femoral
• D. Carotid

Correct answer: B

Rationale: When assessing for a pulse in an unresponsive 6-month-old patient, the brachial artery is the recommended site for palpation. This is because the brachial artery is easily accessible and provides a reliable indication of the patient's circulatory status in infants.

2. A 3-year-old is seen in the clinic and is diagnosed with an ear infection. The father reports that the child was awake several times during the night, crying. The PRIORITY nursing diagnosis for this child is:

• A. Sleep Pattern Disturbance related to pain.
• B. Pain related to ear infection.
• C. Altered Family Processes related to ill child.
• D. Ineffective Thermoregulation Related to Infection

Correct answer: B

Rationale: The priority nursing diagnosis for a child diagnosed with an ear infection and experiencing nighttime awakenings and crying would be 'Pain related to ear infection.' Pain management is crucial to ensure the child's comfort and well-being, which can also impact their sleep patterns. Addressing the pain as a priority can lead to improved sleep and overall recovery for the child.

3. A postpartum client is experiencing difficulty voiding. What should the nurse include in the care plan to assist the client?

• A. Encourage the client to drink caffeine-free beverages.
• B. Apply a warm compress to the client's lower abdomen.
• C. Encourage increased fluid intake to promote urinary flow.
• D. Assist the client with Kegel exercises.

Correct answer: B

Rationale: Applying a warm compress to the lower abdomen can help relax the muscles and stimulate voiding in postpartum clients. It promotes vasodilation, increases blood flow to the area, and can aid in relieving urinary retention. Encouraging caffeine-free beverages can also be beneficial as caffeine can irritate the bladder and worsen the situation. Increasing fluid intake helps prevent urinary stasis and promotes bladder emptying. Kegel exercises can strengthen pelvic floor muscles over time, but in the immediate situation of difficulty voiding, a warm compress is more appropriate.

4. What is the appropriate treatment for a responsive 4-year-old child with a mild airway obstruction, respiratory distress, a strong cough, and normal skin color?

• A. Oxygen, back slaps, and transport.
• B. Subdiaphragmatic thrusts until the object is expelled.
• C. Assisted ventilations, back slaps, and transport.
• D. Supplemental oxygen and transport.

Correct answer: D

Rationale: For a responsive 4-year-old child with a mild airway obstruction, respiratory distress, a strong cough, and normal skin color, the appropriate treatment includes providing supplemental oxygen and arranging for transport to a healthcare facility. Oxygen helps alleviate the respiratory distress, and transport ensures the child receives further evaluation and care by healthcare professionals. Back slaps and subdiaphragmatic thrusts are not recommended for a child with a mild airway obstruction and normal skin color, as these interventions are typically reserved for more severe cases of airway obstruction.

5. Fred, a 12-year-old boy, is diagnosed with pneumococcal pneumonia. Which of the following symptoms would Nurse Nica expect to assess?

• A. Mild cough
• B. Slight fever
• C. Chest pain
• D. Bulging fontanel

Correct answer: C

Rationale: Chest pain is a common symptom associated with pneumococcal pneumonia. It can occur due to inflammation of the pleura or irritation of the lung tissue, leading to sharp or stabbing pain that worsens with breathing or coughing. While cough and fever are also common with pneumonia, chest pain is particularly significant in this case.

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