Nursing Elites

1. What should be included in the preoperative teaching for a 4-year-old child scheduled for a tonsillectomy?

• A. Explaining the procedure in detail
• B. Encouraging deep breathing exercises
• C. Discussing the importance of hydration
• D. Using play therapy to prepare the child

Correct answer: B

Rationale: Encouraging deep breathing exercises is important preoperative teaching for a child scheduled for a tonsillectomy. Deep breathing exercises can help the child relax and reduce anxiety, which is beneficial before the procedure. Explaining the procedure in detail might be overwhelming for a 4-year-old, whereas encouraging deep breathing exercises can be more beneficial in promoting relaxation and preparing the child. Discussing the importance of hydration is crucial for postoperative care but may not be the priority for preoperative teaching. Using play therapy can help prepare the child, but encouraging deep breathing exercises is more directly related to relaxation and preparation for the procedure.

2. While assessing an 18-month-old child, a nurse observes that the toddler can crawl upstairs but needs assistance when climbing the stairs upright. What does this action indicate to the nurse?

• A. Presence of talipes equinovarus
• B. Reflective of neurologic damage
• C. Expected behavior in a toddler of this age
• D. Existence of developmental dysplasia of the hip

Correct answer: C

Rationale: The correct answer is C. Needing assistance to climb stairs is considered expected behavior for an 18-month-old toddler. At this age, children are still developing their gross motor skills, coordination, and balance, which can vary in proficiency. It is common for toddlers to be able to crawl upstairs before mastering the skill of climbing stairs upright. Options A, B, and D are incorrect because at 18 months, it is normal for children to require help and practice with climbing stairs and does not necessarily point to any specific medical conditions or developmental issues.

3. A child with sickle cell anemia develops severe chest pain, fever, a cough, and dyspnea. What should the nurse do first?

• A. Administer 100% oxygen to relieve hypoxia
• B. Administer pain medication to relieve symptoms
• C. Notify the practitioner because chest syndrome is suspected
• D. Notify the practitioner because the child may be having a stroke

Correct answer: C

Rationale: The correct action to take first when a child with sickle cell anemia presents with severe chest pain, fever, cough, and dyspnea is to notify the practitioner because acute chest syndrome is suspected. This condition is a medical emergency requiring prompt intervention. Administering oxygen or pain medication may be necessary interventions but should not precede notifying the practitioner. Stroke is not typically associated with these symptoms in sickle cell anemia.

4. A child with a diagnosis of gastroenteritis is admitted to the hospital. What is the priority nursing intervention?

• A. Monitoring fluid and electrolyte balance
• B. Encouraging regular exercise
• C. Administering antipyretics
• D. Administering antibiotics

Correct answer: A

Rationale: The correct answer is monitoring fluid and electrolyte balance. Gastroenteritis is characterized by inflammation of the gastrointestinal tract leading to diarrhea and vomiting, which can result in dehydration and electrolyte imbalances. Therefore, the priority nursing intervention is to monitor and maintain the child's fluid and electrolyte balance to prevent complications. Encouraging regular exercise (Choice B) may not be appropriate initially for a child with gastroenteritis who needs rest and fluid replacement. Administering antipyretics (Choice C) is not the priority unless the child has a fever. Administering antibiotics (Choice D) is not indicated for viral gastroenteritis, which is the most common cause of the condition.

5. When assessing the perfusion status of a 2-year-old child with possible shock, which of the following parameters would be LEAST reliable?

• A. distal capillary refill
• B. systolic blood pressure
• C. skin color and temperature
• D. presence of peripheral pulses

Correct answer: B

Rationale: The correct answer is B: systolic blood pressure. In young children, systolic blood pressure is the least reliable parameter for assessing perfusion status. Factors such as anxiety, crying, and fear can significantly affect blood pressure measurements, leading to inaccuracies. Distal capillary refill, skin color and temperature, and presence of peripheral pulses are more reliable indicators of perfusion status in pediatric patients. Distal capillary refill assesses peripheral perfusion, skin color, and temperature reflect tissue perfusion, and the presence of peripheral pulses indicates blood flow to the extremities. Therefore, when evaluating a 2-year-old child with possible shock, focusing on parameters other than systolic blood pressure is crucial for an accurate assessment of perfusion status.

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