Nursing Elites

1. A 2-year-old child with a diagnosis of gastroesophageal reflux disease (GERD) is being discharged. What dietary instructions should the nurse provide?

• A. Avoid spicy foods
• B. Avoid gluten
• C. Avoid high-fat foods
• D. Avoid dairy products

Correct answer: C

Rationale: Avoiding gluten is not typically necessary for managing gastroesophageal reflux disease (GERD) in children. The correct dietary instruction for a 2-year-old with GERD would be to avoid high-fat foods. High-fat foods can relax the lower esophageal sphincter, leading to increased reflux symptoms. While spicy foods and dairy products may also trigger reflux in some individuals, the primary focus should be on avoiding high-fat foods due to their direct impact on the lower esophageal sphincter, which exacerbates GERD symptoms.

2. A parent calls the clinic because their child has ingested a small amount of household bleach. What should the nurse advise?

• A. Administer activated charcoal
• B. Induce vomiting immediately
• C. Call the poison control center
• D. Take the child to the emergency department

Correct answer: C

Rationale: In the case of a child ingesting household bleach, the primary advice should be to call the poison control center (Choice C). The poison control center can provide specific guidance on how to manage the ingestion, including whether any immediate interventions are necessary. Administering activated charcoal (Choice A) or inducing vomiting immediately (Choice B) can worsen the situation as they are not recommended treatments for bleach ingestion. Taking the child to the emergency department (Choice D) may be necessary depending on the advice given by the poison control center, but the initial step should be to seek guidance from the experts at the poison control center.

3. A child with a diagnosis of leukemia is admitted to the hospital with a fever. What is the priority nursing intervention?

• A. Administering antibiotics
• B. Administering antipyretics
• C. Providing nutritional support
• D. Monitoring for signs of infection

Correct answer: D

Rationale: The priority nursing intervention for a child with leukemia admitted to the hospital with a fever is to monitor for signs of infection. Children with leukemia are immunocompromised, making them more susceptible to infections. Monitoring for signs of infection helps in early detection and timely intervention, which is crucial in preventing complications. Administering antibiotics (choice A) may be necessary if an infection is suspected or confirmed, but the priority is to assess for signs of infection first. Administering antipyretics (choice B) may help reduce fever, but it does not address the underlying cause, which could be an infection. Providing nutritional support (choice C) is important for overall health but is not the priority when a child with leukemia presents with a fever, as infection needs to be ruled out or managed first.

4. A 1-week-old infant has been in the pediatric unit for 18 hours following placement of a spica cast. The nurse observes a respiratory rate of fewer than 24 breaths/min. No other changes are noted. Because the infant is apparently well, the nurse does not report or document the slow respiratory rate. Several hours later, the infant experiences severe respiratory distress and emergency care is necessary. What should be considered if legal action is taken?

• A. Most infants have slow respirations when they are uncomfortable.
• B. The respirations of young infants are irregular, so a drop in rate is unimportant.
• C. Vital signs that are outside the expected parameters are significant and should be documented.
• D. The respiratory tract of young infants is underdeveloped, and their respiratory rate is not significant.

Correct answer: C

Rationale: In this scenario, the correct answer is C. Any vital signs outside the expected range in an infant should be documented and reported, as they may indicate a developing condition that requires prompt attention. Choice A is incorrect because slow respirations in infants should not be dismissed without assessment and documentation. Choice B is incorrect because a drop in respiratory rate in this case was significant and should have been documented. Choice D is incorrect because even though infants have underdeveloped respiratory tracts, any abnormal respiratory rate should be taken seriously and documented for monitoring and intervention if necessary.

5. How should you care for an alert 4-year-old child with a mild airway obstruction, who has respiratory distress, a strong cough, and normal skin color?

• A. Back blows, abdominal thrusts, transport
• B. Oxygen, avoiding agitation, transport
• C. Assisting ventilations, back blows, transport
• D. Chest thrusts, finger sweeps, transport

Correct answer: B

Rationale: The correct approach for an alert 4-year-old child with a mild airway obstruction, respiratory distress, a strong cough, and normal skin color is to provide oxygen, avoid agitation, and arrange for transport. Oxygen helps support breathing, avoiding agitation prevents worsening of the obstruction, and transport ensures the child receives further medical evaluation and treatment. Choices A, C, and D involve techniques that are not recommended for a mild airway obstruction in this scenario. Back blows, abdominal thrusts, chest thrusts, and finger sweeps are interventions used for different situations and not suitable for a child with the described symptoms.

Similar Questions