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 urinary diversion procedure is the least damaging to the body image of the adolescent?

• A. Urostomy
• B. Ileal conduit
• C. Nephrostomy
• D. Suprapubic placement

Correct answer: B

Rationale: The correct answer is B: Ileal conduit. The ileal conduit diverts urine to the colon, and the urine is excreted with the feces. Unlike urostomy, nephrostomy, and suprapubic placement, the ileal conduit does not require an external appliance, which can be less damaging to an adolescent's body image.

3. The healthcare provider should question an order for glucocorticoids in the treatment of a patient with what condition?

• A. Systemic fungal infection
• B. Diabetes Mellitus
• C. Myasthenia Gravis
• D. Glaucoma

Correct answer: A

Rationale: Glucocorticoids are contraindicated in the treatment of a patient with systemic fungal infection or in patients receiving live vaccines due to their immunosuppressive effects. Glucocorticoids can exacerbate fungal infections by suppressing the immune response. While caution is advised in patients with diabetes mellitus, myasthenia gravis, and glaucoma, the presence of a systemic fungal infection warrants questioning the use of glucocorticoids to prevent worsening of the fungal infection.

4. During a physical assessment of a hospitalized 5-year-old child, the healthcare provider notes that the foreskin has been retracted and is very tight on the shaft of the penis; they are unable to return it over the head of the penis. What action should the healthcare provider implement?

• A. Forcibly push the foreskin down over the head of the penis.
• B. Place a warm compress on the penis.
• C. Notify the healthcare provider in charge.
• D. Wait a few hours and try again.

Correct answer: C

Rationale: The correct action is to notify the healthcare provider in charge of this occurrence of paraphimosis. Paraphimosis is a urologic emergency where the foreskin is retracted and becomes tight, potentially impeding blood flow to the penis. It is crucial to seek medical intervention promptly to prevent complications.

5. When caring for an infant with respiratory syncytial virus (RSV), which of the following actions should the nurse take?

• A. Administer antibiotics IM once per day.
• B. Initiate droplet precautions.
• C. Place the infant in a negative-pressure isolation room.
• D. Suction the nasopharynx as needed.

Correct answer: D

Rationale: When caring for an infant with respiratory syncytial virus (RSV), maintaining a patent airway is crucial. Suctioning the nasopharynx as needed helps clear secretions, prevent airway obstruction, and promote effective breathing. This intervention can aid in improving the infant's respiratory status and overall comfort. Administering antibiotics IM once per day (Choice A) is not indicated for RSV as it is caused by a virus, not bacteria. Initiating droplet precautions (Choice B) is important to prevent the spread of respiratory infections like RSV, but directly caring for the infant involves more specific interventions. Placing the infant in a negative-pressure isolation room (Choice C) is generally reserved for airborne infections, not RSV which spreads through respiratory droplets.

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