Nursing Elites

1. A healthcare provider is assessing a 3-month-old infant with suspected pyloric stenosis. What clinical manifestation is the healthcare provider likely to observe?

• A. Projectile vomiting
• B. Diarrhea
• C. Constipation
• D. Abdominal distension

Correct answer: A

Rationale: Projectile vomiting is a classic clinical manifestation of pyloric stenosis in infants. This occurs due to the narrowing of the pyloric sphincter, leading to the forceful expulsion of gastric contents in a projectile manner. Diarrhea (choice B) is not typically associated with pyloric stenosis. Constipation (choice C) is also not a common symptom of this condition. Abdominal distension (choice D) may occur in pyloric stenosis but is not as specific or characteristic as projectile vomiting in diagnosing this condition.

2. An 8-year-old girl was diagnosed with a closed fracture of the radius at approximately 2 p.m. The fracture was reduced in the emergency department and her arm placed in a cast. At 11 p.m. her mother brings her back to the emergency department due to unrelenting pain that has not been relieved by the prescribed narcotics. Which action would be the priority?

• A. Notifying the doctor immediately
• B. Applying ice
• C. Elevating the arm
• D. Giving additional pain medication as ordered

Correct answer: A

Rationale: The correct action would be to notify the doctor immediately. Unrelenting pain despite medication can indicate compartment syndrome, which is a medical emergency requiring immediate attention. Applying ice, elevating the arm, or giving additional pain medication may not address the underlying cause of the unrelenting pain, which could be a sign of a serious complication like compartment syndrome. Prompt medical evaluation is crucial in this situation to prevent potential complications.

3. A child with a diagnosis of leukemia is receiving chemotherapy. What is the priority nursing intervention?

• A. Monitoring for signs of infection
• B. Providing nutritional support
• C. Monitoring for signs of bleeding
• D. Monitoring for signs of pain

Correct answer: A

Rationale: The priority nursing intervention for a child with leukemia receiving chemotherapy is monitoring for signs of infection. Chemotherapy can suppress the immune system, putting the child at a higher risk of developing infections. Early detection of signs of infection is crucial to prevent serious complications and initiate timely treatment. Providing nutritional support is important for overall health but is not the priority when the child is at risk of infection. Monitoring for signs of bleeding is essential, but infection surveillance takes precedence due to the immediate threat it poses to the child's health. Monitoring for signs of pain is important for comfort but is not the priority over infection prevention and management.

4. A nurse is providing care to a child with a diagnosis of bronchiolitis. What is the priority nursing intervention?

• A. Administering bronchodilators
• B. Providing respiratory therapy
• C. Monitoring oxygen saturation
• D. Encouraging fluid intake

Correct answer: B

Rationale: The correct answer is providing respiratory therapy. In bronchiolitis, the priority is to maintain airway patency through interventions such as suctioning, positioning, and oxygen therapy. While bronchodilators may be used in some cases, they are not the initial priority. Monitoring oxygen saturation is important but comes after ensuring airway patency. Encouraging fluid intake is essential for hydration but is not the priority over maintaining a patent airway.

5. When picked up by a parent or the nurse, an 8-month-old infant screams and seems to be in pain. After observing this behavior, what should the nurse discuss with the parent?

• A. Accidents and the importance of preventing them
• B. Limiting the infant's playtime with other children in the family
• C. Any other behaviors that the parent may have noticed
• D. Nutrition and specific vitamins recommended for infants

Correct answer: C

Rationale: Discussing any other observed behaviors with the parent is important to identify patterns or potential issues that could be affecting the infant's well-being. By exploring additional behaviors, the nurse can gather more information to assess the infant comprehensively. This approach allows for a more holistic understanding of the infant's health status, rather than focusing solely on the observed behavior of screaming and apparent pain. Options A, B, and D are incorrect as they do not directly address the need to explore other behaviors that may provide insights into the infant's condition and well-being.

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