Nursing Elites

1. You are dispatched to a residence for a 4-year-old female who is sick. Your assessment reveals that she has increased work of breathing and is making a high-pitched sound during inhalation. Her mother tells you that she has been running a high fever for the past 24 hours. Your MOST immediate concern should be:

• A. determining if the child has a history of croup.
• B. preparing to treat her for a febrile seizure.
• C. assessing the need for ventilation assistance.
• D. taking her temperature to see how high it is.

Correct answer: C

Rationale: In a child with increased work of breathing, a high-pitched sound during inhalation, and a high fever, upper airway obstruction should be suspected. The child's condition may require immediate ventilation assistance to ensure adequate oxygenation and ventilation. Therefore, the most immediate concern in this scenario is to assess the need for ventilation assistance.

2. Management for a woman presenting with a prolapsed umbilical cord includes all of the following, EXCEPT:

• A. lifting the baby's head off the umbilical cord.
• B. placing the mother in a position that elevates her hips.
• C. ensuring that the cord stays moist during transport.
• D. relieving pressure off the cord by gently pulling on it.

Correct answer: D

Rationale: In cases of prolapsed umbilical cord, it is crucial to manage the situation promptly. The correct steps include lifting the baby's head off the umbilical cord to reduce pressure, placing the mother in a position that elevates her hips to relieve pressure on the cord, and ensuring that the cord stays moist. Pulling on the cord is not recommended as it can further compromise fetal circulation and should be avoided. Therefore, relieving pressure off the cord by gently pulling on it is not a recommended management approach in cases of prolapsed umbilical cord.

3. A patient has been diagnosed with hypothyroidism; the nurse tells the patient not to eat goitrogens. Which of the following is an example of a goitrogen?

• A. Orange
• B. Tomatoes
• C. Cabbage
• D. Grapes

Correct answer: C

Rationale: Cabbage is an example of a goitrogen. Goitrogens are substances that can interfere with thyroid function by inhibiting the uptake of iodine. Cabbage contains compounds that can have this effect and should be consumed in moderation by individuals with hypothyroidism.

4. If a baby weighs 14 kg, how much fluid should be administered to the baby over 24 hours using a rate of 100 ml/kg?

• A. 1400ml
• B. 2600ml
• C. 1650ml
• D. 3360ml

Correct answer: A

Rationale: To calculate the fluid requirement for a baby, multiply the weight of the baby (14 kg) by the fluid rate (100 ml/kg): 14 kg x 100 ml/kg = 1400 ml. Therefore, the correct answer is 1400 ml.

5. A toddler is admitted to the hospital because of sudden hoarseness, holding or pointing to their neck, and continuous cough. The nurse will be particularly concerned about:

• A. Acute respiratory tract infection
• B. Respiratory tract obstruction caused by a foreign body
• C. Retropharyngeal abscess
• D. Undetected laryngeal abnormality

Correct answer: B

Rationale: In a toddler presenting with sudden hoarseness, holding or pointing to their neck, and continuous cough, the nurse should be particularly concerned about respiratory tract obstruction caused by a foreign body. These symptoms are indicative of a possible foreign body in the airway, which can lead to serious complications and requires immediate attention to ensure the toddler's airway remains patent and unobstructed.

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