Nursing Elites

1. A child with a diagnosis of cystic fibrosis is admitted to the hospital. What is the priority nursing intervention?

• A. Administering pancreatic enzymes
• B. Providing respiratory therapy
• C. Providing nutritional support
• D. Encouraging physical activity

Correct answer: A

Rationale: The correct answer is administering pancreatic enzymes. In cystic fibrosis, the pancreas is often affected, leading to insufficient production of digestive enzymes. Administering pancreatic enzymes is crucial to ensure proper digestion and absorption of nutrients. While respiratory therapy, nutritional support, and physical activity are essential components of care for individuals with cystic fibrosis, addressing the digestive aspect by administering pancreatic enzymes takes priority to prevent malnutrition and promote overall health.

2. A 7-month-old girl is to be catheterized to obtain a sterile urine specimen. One of the infant’s parents expresses fear that this procedure may traumatize the baby psychologically. How should the nurse provide reassurance?

• A. The fear is justified and the nurse should obtain a “clean catch” specimen.
• B. Parents have a right to refuse the catheterization and the concerns are realistic.
• C. Although the concern is appropriate, the need for a sterile specimen is the priority.
• D. The procedure is uncomfortable, but there should not be a damaging long-term effect.

Correct answer: D

Rationale: While catheterization can be uncomfortable, it does not typically result in long-term psychological harm, and obtaining a sterile specimen is important for accurate diagnosis.

3. Which of the following statements regarding 2-rescuer child CPR is correct?

• A. The chest should not be allowed to fully recoil in between compressions as this may impede venous return.
• B. Compress the chest with one or two hands to a depth equal to one-half to one third the diameter of the chest.
• C. The chest should be compressed with one hand and a compression to ventilation ratio of 30:2 should be delivered.
• D. A compression to ventilation ratio of 15:2 should be delivered without pauses in compressions to deliver ventilations.

Correct answer: B

Rationale: The correct statement regarding 2-rescuer child CPR is to compress the chest with one or two hands to a depth equal to one-half to one third the diameter of the chest. This technique ensures effective chest compressions without causing excessive damage to the chest. Choice A is incorrect because allowing the chest to fully recoil between compressions is essential to facilitate optimal blood flow during CPR. Choice C is incorrect as it describes a compression to ventilation ratio of 30:2, which is not the recommended ratio for child CPR. Choice D is incorrect as a compression to ventilation ratio of 15:2 is not standard practice for child CPR, and pauses in compressions are necessary to provide ventilations effectively.

4. Parents of a sick infant talk with a nurse about their baby. One parent says, “I am so upset; I didn’t realize our baby was ill.” What major indication of illness in an infant should the nurse explain to the parent?

• A. Grunting respirations
• B. Excessive perspiration
• C. Longer periods of sleep
• D. Crying immediately after feedings

Correct answer: C

Rationale: The correct answer is C. Longer periods of sleep than usual can be a sign of illness in infants. When an infant sleeps more than usual, it can indicate that the baby is conserving energy due to an underlying condition. Grunting respirations (choice A) can be a sign of respiratory distress, not just an indication of illness. Excessive perspiration (choice B) can occur due to various reasons and is not a specific major indication of illness. Crying immediately after feedings (choice D) is a common behavior in infants and not necessarily a major indication of illness.

5. A child with a diagnosis of pyloric stenosis is scheduled for surgery. What preoperative intervention is important for the nurse to perform?

• A. Administering intravenous fluids
• B. Monitoring for signs of infection
• C. Monitoring for signs of dehydration
• D. Monitoring for signs of pain

Correct answer: C

Rationale: The correct preoperative intervention for a child with pyloric stenosis is to monitor for signs of dehydration. Pyloric stenosis involves the obstruction of the pyloric sphincter, leading to projectile vomiting, which can result in dehydration and electrolyte imbalances. Monitoring for signs of dehydration is crucial to assess the child's fluid status and prevent complications. Administering intravenous fluids, although important in managing dehydration, is not typically a preoperative intervention but rather a treatment during or after surgery. Monitoring for signs of infection and pain may also be important but are not the priority preoperative interventions in a child with pyloric stenosis.

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