Nursing Elites

1. A 6-year-old child is admitted to the hospital with pneumonia. An immediate priority in this child's nursing care would be:

• A. Elimination
• B. Exercise
• C. Nutrition
• D. Rest

Correct answer: D

Rationale: Rest is crucial for recovery in a child with pneumonia as it allows the body to focus its energy on fighting the infection and promoting healing. Adequate rest helps reduce the workload on the lungs, promotes oxygenation, and supports the immune system's response to combat the infection. It is essential to prioritize rest to facilitate a faster recovery and prevent complications in children with pneumonia.

2. A child newly diagnosed with diabetes mellitus has been stabilized with insulin injections daily. A nurse prepares a discharge teaching plan regarding the insulin. The teaching plan should reinforce which of the following concepts?

• A. Always store insulin vials in the refrigerator
• B. Adjust insulin dosage before exercise
• C. Presence of ketones in urine indicates a need for less insulin
• D. Systematically rotate injection sites

Correct answer: D

Rationale: Systematically rotating injection sites is crucial to prevent tissue damage and ensure optimal insulin absorption. This practice helps in preventing lipohypertrophy, a condition characterized by fat accumulation at injection sites, which can affect insulin absorption and lead to inconsistent blood glucose control. By rotating injection sites, the risk of skin and tissue damage is minimized, and insulin's effectiveness is maintained over time.

3. How can a new mother tell if her baby is getting enough breast milk?

• A. If your baby sleeps through the night, they are getting enough milk.
• B. If your baby has six to eight wet diapers a day, they are getting enough milk.
• C. If your baby cries frequently, they are getting enough milk.
• D. If your baby is awake and alert, they are getting enough milk.

Correct answer: B

Rationale: The correct answer is B. If a new mother observes that her baby has six to eight wet diapers a day, it indicates that the baby is getting enough breast milk. This is a crucial indicator of adequate milk intake and hydration in infants. Conversely, choices A, C, and D are incorrect. A baby sleeping through the night, crying frequently, or being awake and alert are not reliable indicators of sufficient breast milk intake. It is essential for new mothers to track their baby's diaper output to ensure they are receiving the necessary nutrition.

4. During transport of a woman in labor, the patient tells you that she feels the urge to push. You assess her and see the top of the baby's head bulging from the vagina. What should you do?

• A. Ask the mother to take short, quick breaths until you arrive at the hospital.
• B. Allow the head to deliver and check for the location of the cord.
• C. Apply gentle pressure to the baby's head and notify the hospital immediately.
• D. Advise your partner to stop the ambulance and assist with the delivery.

Correct answer: D

Rationale: When the top of the baby's head is visible (crowning) during transport, it indicates imminent delivery. In this situation, it is crucial to stop the ambulance and assist with the delivery. This ensures a safe delivery process for the mother and the baby. Waiting to arrive at the hospital or attempting to apply pressure to the baby's head can lead to complications. Allowing the head to deliver and checking for the cord's location is a necessary step during the delivery process, but the immediate priority is to assist in the safe delivery of the baby.

5. In which stage do you determine if the patient has achieved the expected outcomes?

• A. Implementation
• B. Evaluation
• C. Assessment
• D. Diagnosis

Correct answer: B

Rationale: Evaluation is the correct stage in the nursing process to determine if the patient has achieved the expected outcomes. During the evaluation stage, the healthcare provider assesses the effectiveness of the care plan and decides on any necessary adjustments to reach the desired goals. Choice A, Implementation, is incorrect because this stage involves putting the care plan into action. Choice C, Assessment, is incorrect as it is the stage where data about the patient's health status is gathered. Choice D, Diagnosis, is also incorrect as it is the stage where the healthcare provider identifies the patient's health problems based on the assessment data.

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