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. A child is being assessed for suspected intussusception. What clinical manifestation is the nurse likely to observe?

• A. Projectile vomiting
• B. Currant jelly stools
• C. Abdominal distension
• D. Constipation

Correct answer: C

Rationale: The correct clinical manifestation that a nurse is likely to observe in a child with suspected intussusception is abdominal distension. Intussusception is a medical emergency where a part of the intestine folds into itself, causing obstruction. Abdominal distension is a common symptom due to the obstruction and the build-up of gases and fluids. While currant jelly stools (Choice B) are a classic sign of intussusception, they are typically seen in later stages of the condition and may not be present during the initial assessment. Projectile vomiting (Choice A) is more commonly associated with conditions like pyloric stenosis. Constipation (Choice D) is not a typical manifestation of intussusception; the condition usually presents with severe colicky abdominal pain and possible passage of blood and mucus in stools.

3. Surgical repair for patent ductus arteriosus (PDA) is done to prevent the complication of

• A. pulmonary infection
• B. right-to-left shunt of blood
• C. decreased workload on the left side of the heart
• D. increased pulmonary vascular congestion

Correct answer: D

Rationale: Surgical repair of patent ductus arteriosus (PDA) aims to prevent increased pulmonary vascular congestion, which can lead to congestive heart failure and respiratory distress. Choice A, pulmonary infection, is not a direct complication of PDA but rather a result of other factors. Choice B, right-to-left shunt of blood, is a characteristic of a different heart condition (e.g., Tetralogy of Fallot) and not specifically associated with PDA. Choice C, decreased workload on the left side of the heart, is not a typical complication of PDA but rather a consequence of left-to-right shunting that can cause volume overload in the pulmonary circulation.

4. An order is written for an isotonic enema for a 2-year-old child. What is the maximum amount of fluid the nurse should administer without a specific order from the healthcare provider?

• A. 100 to 150 mL
• B. 155 to 250 mL
• C. 255 to 360 mL
• D. 365 to 500 mL

Correct answer: B

Rationale: For a 2-year-old child, the maximum recommended amount of fluid for an isotonic enema is between 155 to 250 mL. This range is considered safe to prevent overdistension and potential harm to the child's rectum. Choices A, C, and D exceed the safe range for a 2-year-old child and can lead to complications such as bowel perforation or electrolyte imbalances.

5. When the working mother of a toddler is preparing to take her child home after a prolonged hospitalization, she asks the nurse what type of behavior she should expect to be displayed. What is the nurse’s most appropriate description of her child’s probable behavior?

• A. Excessively demanding behavior
• B. Hostile attitude toward the mother
• C. Cheerful, with shallow attachment behaviors
• D. Withdrawn, without emotional ties to the mother

Correct answer: A

Rationale: After a prolonged hospitalization, a toddler may exhibit excessively demanding behavior as they readjust to being home. This behavior can stem from the child feeling insecure or anxious about the changes in their environment. The child may seek extra attention and reassurance during this transition period. Choices B, C, and D are incorrect because hostility, shallowness in attachment, and withdrawal without emotional ties are less likely behaviors to be displayed by a toddler readjusting to home after a hospital stay.

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