Nursing Elites

1. A nurse administers naloxone (Narcan) to a post-op patient experiencing respiratory sedation. What undesirable effect would the nurse anticipate after giving this medication?

• A. Drowsiness
• B. Tics and tremors
• C. Increased Pain
• D. Nausea and vomiting

Correct answer: C

Rationale: Naloxone reverses the effects of narcotics. Although the patient�s respiratory status will improve after administration of naloxone, the pain will be more acute.

2. In an immunization clinic, which patient will the nurse identify as not eligible to receive routine immunizations?

• A. An 8-year-old experiencing diarrhea
• B. A 2-year-old with a history of pre-term birth
• C. A 4-year-old with a fever and upper respiratory tract infection
• D. A 6-year-old who has been recently exposed to a classmate with chickenpox

Correct answer: C

Rationale: The nurse should identify the 4-year-old with a fever and upper respiratory tract infection as not eligible to receive routine immunizations. It is contraindicated to administer vaccines in the presence of moderate to severe illness, whether with or without fever, to prevent potential complications or reduced vaccine efficacy.

3. Which clinical manifestation should a nurse monitor for when assessing a pediatric client diagnosed with a basilar skull fracture?

• A. Periorbital ecchymosis
• B. Subdural hematoma
• C. Protruding bone
• D. Epidural hematoma

Correct answer: A

Rationale: Periorbital ecchymosis, also known as raccoon eyes, is a classic sign of a basilar skull fracture. It presents as bruising around the eyes due to blood collecting in the tissues. Monitoring for periorbital ecchymosis is crucial in assessing a pediatric client with a basilar skull fracture because it can indicate the presence of this serious injury.

4. A healthcare professional is planning care for an infant with hyperbilirubinemia receiving phototherapy. Which of the following actions should the healthcare professional include in the plan?

• A. Dress the infant in light, breathable clothing.
• B. Turn and reposition the infant every 4 hours.
• C. Offer the infant frequent, small feedings.
• D. Avoid using lotions on the infant's skin.

Correct answer: B

Rationale: Turning and repositioning the infant every 4 hours is essential to prevent pressure sores and ensure uniform exposure to phototherapy. This practice helps prevent skin breakdown and ensures the effectiveness of the phototherapy in treating hyperbilirubinemia. Dressing the infant in light, breathable clothing (Choice A) is generally a good practice but not directly related to the effectiveness of phototherapy. Offering frequent, small feedings (Choice C) is important for infant nutrition but does not directly impact the phototherapy. Avoiding lotions on the infant's skin (Choice D) is recommended to prevent interference with the phototherapy but is not the most critical action to include in the care plan.

5. A child is being assessed for possible appendicitis with perforation. Which of the following findings should the nurse expect?

• A. Hyperactive bowel sounds
• B. Abdominal distension
• C. Hypoactive bowel sounds
• D. Bradycardia

Correct answer: D

Rationale: In a child with appendicitis and possible perforation, the nurse should expect bradycardia due to peritoneal irritation. Bradycardia is a common response to peritoneal inflammation or infection, indicating a possible serious complication. Hyperactive bowel sounds, abdominal distension, and hypoactive bowel sounds are more commonly associated with other gastrointestinal conditions and are less likely to be present in a child with appendicitis and perforation. Therefore, the correct answer is bradycardia (D) as it aligns with the expected physiological response in this scenario.

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