Nursing Elites

1. While auscultating the lungs of an adolescent with asthma, what should the nurse identify the sound as?

• A. Biots respiration
• B. Chaney-Stokes respiration
• C. Tachypnea
• D. Bradypnea

Correct answer: C

Rationale: The nurse should identify the sound heard during auscultation as tachypnea, which is characterized by a rapid, regular breathing pattern. In the case of an adolescent with asthma, tachypnea can be indicative of increased work of breathing due to airway constriction and inflammation. Biots respiration (choice A) is characterized by an irregular pattern of breathing with periods of apnea. Chaney-Stokes respiration (choice B) is a pattern of breathing characterized by alternating periods of deep, rapid breathing followed by periods of apnea. Bradypnea (choice D) refers to an abnormally slow breathing rate, which is not typically associated with asthma exacerbation.

2. Which strategy is most likely to promote positive behavior in children?

• A. Providing flexible instructions with no consequences
• B. Limiting opportunities until the child performs adequately
• C. Improving the child's competence and creating a positive environment
• D. Setting strict rules with punishments for misbehavior

Correct answer: C

Rationale: Improving the child's competence and creating a positive environment is the most effective strategy to promote positive behavior in children. This approach focuses on enhancing the child's skills and abilities while fostering a supportive and encouraging atmosphere. By empowering the child and surrounding them with positivity, they are more likely to exhibit positive behaviors as they feel competent, valued, and motivated. This strategy emphasizes support and reinforcement over punitive measures, leading to long-lasting behavioral improvements.

3. Following a child's return from exploratory surgery due to a gunshot wound to the abdomen, which nursing intervention should be excluded from the plan of care?

• A. Immediate initiation of oral feedings
• B. Assessment of the surgical site
• C. Administration of opioid narcotics for pain management
• D. Visitation at the bedside

Correct answer: A

Rationale: Immediate initiation of oral feedings should be excluded from the plan of care post-abdominal surgery due to the risk of bowel complications like paralytic ileus or anastomotic leak. Starting oral feedings immediately can increase these risks and hinder healing. It is crucial to wait until bowel function returns and the patient shows signs of tolerance before introducing oral feedings. Assessment of the surgical site is necessary to monitor for any signs of infection or complications. Administration of opioid narcotics for pain management is essential for ensuring the patient's comfort post-surgery. Visitation at the bedside provides emotional support and can aid in the patient's recovery. Therefore, the correct answer is to exclude immediate initiation of oral feedings.

4. A school-age child has peripheral edema. Which of the following assessments should the nurse perform to confirm peripheral edema?

• A. Palpate the dorsum of the child's feet
• B. Weigh the child daily using the same scale
• C. Assess the child's skin turgor
• D. Observe the child for periorbital swelling

Correct answer: A

Rationale: To confirm peripheral edema in a child, the nurse should palpate the dorsum of the child's feet by pressing a fingertip against a bony prominence for 5 seconds. This assessment helps detect the presence of pitting edema, which is characterized by an indentation that remains after the pressure is released.

5. Which assessment finding for a 4-month-old infant would require further action by the nurse?

• A. The posterior fontanel is open.
• B. The infant has good head control when held upright.
• C. The infant is able to roll only from abdomen to back.
• D. The anterior fontanel is open and soft.

Correct answer: A

Rationale: The correct answer is A. The posterior fontanel should be closed by 4 months of age. An open posterior fontanel at this age may indicate a delay in normal closure, which could be a cause for concern and require further evaluation by the healthcare provider to ensure proper development and growth. Choices B, C, and D are typical developmental milestones for a 4-month-old infant and do not raise immediate concerns requiring further action by the nurse.

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