Nursing Elites

1. A child with a diagnosis of sickle cell anemia is experiencing a vaso-occlusive crisis. What is the most important nursing intervention?

• A. Administering oxygen
• B. Administering pain medication
• C. Monitoring fluid intake
• D. Encouraging physical activity

Correct answer: B

Rationale: During a vaso-occlusive crisis in sickle cell anemia, the most important nursing intervention is to administer pain medication. Pain management is crucial in alleviating the intense pain experienced by the patient. Administering oxygen (Choice A) may be necessary in some cases to improve oxygenation, but pain relief takes precedence during a vaso-occlusive crisis. Monitoring fluid intake (Choice C) is important for hydration but is not the priority during a crisis. Encouraging physical activity (Choice D) is contraindicated during a vaso-occlusive crisis as it can exacerbate pain and tissue damage.

2. A nurse is reviewing the immunization schedule of an 11-month-old infant. What immunizations does the nurse expect the infant to have previously received?

• A. Pertussis, tetanus, polio, and measles
• B. Diphtheria, pertussis, tetanus, and polio
• C. Rubella, polio, tuberculosis, and pertussis
• D. Measles, mumps, rubella, and tuberculosis

Correct answer: B

Rationale: By 11 months of age, the recommended vaccines for infants include diphtheria, pertussis, tetanus, and polio. These vaccines are part of the routine immunization schedule to protect infants from serious infectious diseases. Choice A is incorrect because measles is not typically administered at this age. Choice C is incorrect because rubella and tuberculosis are not part of routine infant immunizations. Choice D is incorrect because measles, mumps, and rubella are usually given as a combination vaccine later in childhood, not at 11 months of age.

3. The nurse is caring for a 12-year-old boy with idiopathic thrombocytopenia. The nurse is providing discharge instructions about home care and safety recommendations to the boy and his parents. Which response indicates a need for further teaching?

• A. We should avoid aspirin and drugs like ibuprofen.
• B. He should avoid participating in football for safety.
• C. Swimming would be a great activity.
• D. Our son cannot take any antihistamines.

Correct answer: B

Rationale: The correct answer is B. Participation in contact sports like football should be avoided in children with idiopathic thrombocytopenia due to the increased risk of bleeding. Choices A, C, and D are incorrect because avoiding aspirin and drugs like ibuprofen, engaging in activities like swimming, and avoiding antihistamines are all appropriate recommendations for a child with idiopathic thrombocytopenia to prevent bleeding episodes and ensure safety.

4. A child has been admitted to the pediatric unit with a severe asthma attack. What type of acid-base imbalance should the nurse expect the child to develop?

• A. metabolic alkalosis caused by decreased acid metabolites production
• B. respiratory alkalosis caused by decreased respiratory rate and carbon dioxide retention
• C. respiratory acidosis caused by impaired respirations and increased carbonic acid formation
• D. metabolic acidosis caused by the kidneys' inability to compensate for increased carbonic acid production

Correct answer: C

Rationale: In a severe asthma attack, the child is likely to develop respiratory acidosis due to impaired respirations leading to the retention of carbon dioxide, which combines with water to form carbonic acid. This results in the pH imbalance characterized by an excess of carbonic acid. Choices A, B, and D are incorrect. Metabolic alkalosis (Choice A) is not typically associated with severe asthma attacks; respiratory alkalosis (Choice B) would involve a decrease, not an increase, in carbon dioxide levels; and metabolic acidosis (Choice D) is not the primary acid-base imbalance seen in severe asthma attacks.

5. What should be used to feed an infant born with a unilateral cleft lip and palate?

• A. Plastic spoon
• B. Cross-cut nipple
• C. Parenteral infusion
• D. Rubber-tipped syringe

Correct answer: B

Rationale: A cross-cut nipple is the most appropriate choice for feeding an infant with a unilateral cleft lip and palate. Using a cross-cut nipple helps regulate the flow of milk, making feeding easier for the infant and reducing the risk of aspiration. Plastic spoons, parenteral infusion, and rubber-tipped syringes are not recommended for feeding infants with cleft lip and palate as they can pose risks such as choking, aspiration, or inadequate milk intake. It is essential to choose a feeding method that minimizes these risks and ensures proper nutrition for the infant.

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