Nursing Elites

1. Which statement is not a principle of family-centered care?

• A. Respect family autonomy
• B. Provide flexible services
• C. Collaborate with family members
• D. Set strict rules for families to follow

Correct answer: D

Rationale: Family-centered care focuses on respecting family autonomy, providing flexible services, and collaborating with family members to ensure individualized care. Imposing strict rules contradicts the core principles of family-centered care, which prioritize partnership, communication, and shared decision-making between healthcare providers and families. Therefore, setting strict rules for families to follow goes against the collaborative and individualized nature of family-centered care, making it the statement that is not a principle of this approach.

2. Prior to hydrotherapy treatment for wound debridement following a burn injury, which of the following actions should be taken?

• A. Apply topical antimicrobial ointment to the child's wound
• B. Place a mesh gauze dressing over the child's wound
• C. Administer an analgesic to the child
• D. Initiate prophylactic antibiotic therapy for the child

Correct answer: C

Rationale: Corrected Rationale: Prior to hydrotherapy for wound debridement, it is crucial to administer an analgesic to the preschooler. The procedure is known to be extremely painful, and providing analgesia or sedation is essential to manage the discomfort and pain experienced by the child during the treatment. Choice A is incorrect because applying topical antimicrobial ointment is not a pre-procedural requirement but rather a post-procedure wound care step. Choice B is incorrect as placing a mesh gauze dressing does not address the pain management aspect. Choice D is also incorrect as prophylactic antibiotic therapy is not the primary intervention needed before hydrotherapy for wound debridement.

3. The nurse is unsuccessful in inserting a nasogastric tube for a newborn client. The nurse suspects the newborn has esophageal atresia/tracheoesophageal (EA/TE) fistula. Which nursing action is appropriate while waiting for the healthcare provider to further assess the neonate?

• A. Position the newborn in a semi-Fowler position.
• B. Allow the newborn to stay in the nursery for observation.
• C. Offer the newborn pacifier for comfort.
• D. Wrap the newborn in blankets and place in an incubator.

Correct answer: A

Rationale: Positioning the newborn in a semi-Fowler position is appropriate as it helps prevent aspiration in suspected EA/TE fistula. This position helps reduce the risk of regurgitation and aspiration of gastric contents. Placing the newborn in a semi-Fowler position promotes the drainage of secretions and reduces the risk of complications while awaiting further assessment by the healthcare provider.

4. A patient in the emergency department reports taking sildenafil (Viagra) and nitroglycerin 1 hr before sexual activity. Which finding should the nurse immediately report to the physician?

• A. WBC of 3200 cells/mm³
• B. RR of 26 breaths/min
• C. Temp of 38°C
• D. BP of 70/50

Correct answer: D

Rationale: The correct answer is D: BP of 70/50. When sildenafil (Viagra) is taken with nitroglycerin, it can cause severe hypotension that is unresponsive to treatment. The combination of these medications can lead to a dangerous drop in blood pressure. It is crucial to immediately report hypotension in this scenario as it poses a significant risk to the patient's life. It is recommended to allow at least 24 hours to elapse between the last dose of sildenafil and nitroglycerin to prevent such adverse effects. The other vital signs and lab values may be abnormal but do not have the immediate life-threatening implications that severe hypotension does in this context.

5. During an assessment, which manifestation should a healthcare provider expect in an infant with pyloric stenosis?

• A. Bile-stained vomitus
• B. Distended abdomen
• C. Olive-shaped mass in the upper abdomen
• D. Painless, swollen joints

Correct answer: C

Rationale: Pyloric stenosis in infants typically presents with an olive-shaped mass in the upper abdomen due to hypertrophy of the pyloric muscle. This mass can often be palpated during an assessment and is a key characteristic of this condition. Bile-stained vomitus may be seen in conditions such as intestinal obstruction; a distended abdomen can be a nonspecific sign of various conditions, and painless, swollen joints are not typically associated with pyloric stenosis.

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