Nursing Elites

1. A 6-month-old child who had a cleft-lip repair has elbow restraints in place. What nursing intervention should the nurse plan to implement?

• A. Obtain the healthcare provider’s advice as to when the restraints should be removed.
• B. Remove restraints one at a time to provide range of motion exercises.
• C. Record observation of the restraints q2h and ensure that they are in place at all times.
• D. Remove restraints q4h for 30 minutes and place gloves on the child’s hands.

Correct answer: B

Rationale: Removing restraints one at a time for range of motion exercises prevents muscle stiffness and allows assessment of the skin.

2. A two-year-old child with heart failure (HF) is admitted for replacement of a graft for coarctation of the aorta. Prior to administering the next dose of digoxin (Lanoxin), the nurse obtains an apical heart rate of 128 bpm. What action should the nurse take?

• A. Determine the pulse deficit
• B. Administer the scheduled dose
• C. Calculate the safe dose range
• D. Review the serum digoxin level

Correct answer: B

Rationale: The correct action for the nurse to take is to administer the scheduled dose of digoxin. A heart rate of 128 bpm in a two-year-old child with heart failure falls within the safe range for digoxin administration. It indicates that the child's heart rate is not excessively low, which could be a concern for administering digoxin. Therefore, proceeding with the scheduled dose is appropriate in this scenario. Determining the pulse deficit (Choice A) is not necessary in this situation as the heart rate is already obtained. Calculating the safe dose range (Choice C) is not required as the heart rate is within the safe range. Reviewing the serum digoxin level (Choice D) is not needed at this point since the heart rate indicates that administering the next dose is appropriate.

3. A one-day-old neonate develops a cephalohematoma. The nurse should closely assess this neonate for which common complication?

• A. Jaundice.
• B. Poor feeding.
• C. Brain injury.
• D. Hypoglycemia.

Correct answer: A

Rationale: A cephalohematoma is a collection of blood between the skull and the periosteum. As the blood breaks down, there is an increased risk of jaundice due to the release of bilirubin from the breakdown of red blood cells. Jaundice is a common complication associated with cephalohematoma in neonates. Therefore, the nurse should closely monitor the neonate for signs of jaundice and manage it accordingly.

4. The parents of a 3-year-old boy with Duchenne muscular dystrophy (DMD) ask, 'How can our son have this disease? We are wondering if we should have any more children.' What information should the nurse provide these parents?

• A. This is an inherited X-linked recessive disorder, which primarily affects male children in the family.
• B. The male infant had a viral infection that went unnoticed and untreated, leading to muscle damage.
• C. The lack of the protein dystrophin in the mother can impact the XXX muscle groups of males.
• D. Spinal cord damage due to birth trauma during a breech vaginal birth weakens the muscles.

Correct answer: A

Rationale: The correct answer is A. Duchenne muscular dystrophy is an X-linked recessive disorder, meaning the gene mutation causing DMD is located on the X chromosome. Males have one X chromosome and one Y chromosome, so if the X chromosome they inherit from their mother carries the mutated gene, they will develop DMD. Females have two X chromosomes, so they are carriers of the gene but are usually not affected by the disease. Therefore, the nurse should explain to the parents that DMD is an inherited X-linked recessive disorder that primarily affects male children in the family.

5. The nurse is caring for a 5-year-old child with Reye’s syndrome. Which goal of treatment most clearly relates to caring for this child?

• A. Reduce cerebral edema and lower intracranial pressure
• B. Avert hypotension and septic shock
• C. Prevent cardiac arrhythmias and heart failure
• D. Promote kidney perfusion and normal blood pressure

Correct answer: A

Rationale: Reducing cerebral edema and lowering intracranial pressure is the primary goal of treatment for Reye’s syndrome.

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