Nursing Elites

1. Which of the following is an indication of lower respiratory infection?

• A. Cough
• B. Fever
• C. Inability to lie supine
• D. Shortness of breath

Correct answer: C

Rationale: Inability to lie supine is a significant indication of lower respiratory infection. This symptom often occurs due to breathing difficulties and discomfort experienced by individuals with lower respiratory infections, such as pneumonia or bronchitis. It can be caused by lung inflammation, consolidation, or fluid buildup in the lungs, making lying flat uncomfortable or difficult. Monitoring a patient's ability to lie flat can provide valuable information about the severity and progression of a lower respiratory infection.

2. When responding to a call for a 2-year-old child who fell from a second-story window, with the mechanism of injury and the age of the patient in mind, you should suspect that the primary injury occurred to the child's:

• A. chest.
• B. head.
• C. lower extremities.
• D. abdomen.

Correct answer: B

Rationale: In a scenario where a young child falls from a significant height like a second-story window, the primary injury is more likely to be to the head. This is because young children have proportionately larger head sizes compared to their body, making them more susceptible to head injuries in such falls. The chest (Choice A), lower extremities (Choice C), and abdomen (Choice D) are less likely to sustain the primary injury in this scenario, as the impact of the fall and the child's anatomy predispose the head to be the most affected area.

3. When assessing a newborn for jaundice, which area should be examined?

• A. Legs and feet
• B. Chest and abdomen
• C. Face and sclera
• D. Back and buttocks

Correct answer: C

Rationale: When assessing a newborn for jaundice, the healthcare provider should examine the face and sclera. Jaundice is often first noticeable in these areas due to the buildup of bilirubin, causing a yellowish discoloration of the skin and eyes. Examining the legs and feet (Choice A) is not the most appropriate area for identifying jaundice in newborns. Similarly, the chest and abdomen (Choice B) are not the primary areas where jaundice is usually observed. Checking the back and buttocks (Choice D) is also not as useful as examining the face and sclera when assessing for jaundice in newborns.

4. A 3-year-old female presents with respiratory distress. She is conscious, crying, and clinging to her mother. She has mild intercostal retractions and an oxygen saturation of 93%. The MOST effective way of delivering oxygen to her involves:

• A. gently restraining her and assisting with ventilations.
• B. ventilations with a flow-restricted, oxygen-powered device.
• C. a non-rebreathing mask with the flow rate set at 6 to 8 L/min.
• D. asking the mother to hold an oxygen mask near her face.

Correct answer: C

Rationale: In a pediatric patient with respiratory distress, a non-rebreathing mask with a flow rate set at 6 to 8 L/min is the most effective way to deliver oxygen. This method ensures a high concentration of oxygen is delivered to the child, aiding in improving oxygen saturation levels. In this scenario, the mother can assist in holding the mask to maintain comfort and cooperation in the child while ensuring proper oxygen delivery.

5. One of the signs of CHF is shortness of breath. What is the term for shortness of breath when lying down?

• A. Platypnea
• B. Orthopnea
• C. Apnea
• D. Epistaxis

Correct answer: B

Rationale: Orthopnea is the specific term used to describe shortness of breath when lying down. This condition is commonly seen in patients with congestive heart failure (CHF) due to the redistribution of fluid in the body when changing positions. Platypnea refers to shortness of breath that worsens when sitting or standing, apnea is the cessation of breathing, and epistaxis is the medical term for a nosebleed. Therefore, the correct answer is B (Orthopnea).

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