Nursing Elites

1. A nurse is caring for an infant with intractable vomiting. For what complication is it most important for the nurse to assess?

• A. Acidosis
• B. Alkalosis
• C. Hyperkalemia
• D. Hypernatremia

Correct answer: B

Rationale: When an infant experiences intractable vomiting, it can lead to the loss of stomach acids, resulting in metabolic alkalosis. Alkalosis is characterized by elevated blood pH and can lead to serious complications. Assessing for alkalosis is essential in this scenario to monitor and manage the infant's condition. Choices A, C, and D are incorrect because in this context, the primary concern is the metabolic imbalance caused by excessive vomiting, leading to alkalosis rather than acidosis, hyperkalemia, or hypernatremia.

2. A 6-month-old infant is admitted with a diagnosis of respiratory syncytial virus (RSV). What should the nurse include in the care plan?

• A. Providing small, frequent feedings
• B. Administering antibiotics
• C. Maintaining strict isolation
• D. Elevating the head of the bed

Correct answer: D

Rationale: Elevating the head of the bed is essential in the care of an infant with RSV as it helps improve breathing by reducing congestion and promoting drainage. This position also aids in maintaining patent airways and can enhance comfort for the infant. Providing small, frequent feedings (Choice A) is generally appropriate for infants but is not a specific intervention for RSV. Administering antibiotics (Choice B) is not indicated for RSV, as it is a viral infection and antibiotics are ineffective against viruses. Maintaining strict isolation (Choice C) is important to prevent the spread of infections, but it is not a direct care intervention for managing RSV symptoms.

3. A nurse is caring for a child with a diagnosis of acute lymphoblastic leukemia (ALL). What is the priority nursing intervention?

• A. Administering chemotherapy
• B. Preventing infection
• C. Monitoring for signs of bleeding
• D. Providing nutritional support

Correct answer: A

Rationale: The correct answer is A: Administering chemotherapy. In the care of a child with acute lymphoblastic leukemia (ALL), the priority nursing intervention is administering chemotherapy. Chemotherapy is the primary treatment for ALL and plays a crucial role in managing the disease. While preventing infection, monitoring for signs of bleeding, and providing nutritional support are important aspects of caring for a child with ALL, administering chemotherapy takes precedence as it directly targets the cancer cells and aims to induce remission.

4. On the third day of hospitalization, the nurse observes that a 2-year-old toddler who had been screaming and crying inconsolably begins to regress and is now lying quietly in the crib with a blanket. What stage of separation anxiety has developed?

• A. Denial
• B. Despair
• C. Mistrust
• D. Rejection

Correct answer: B

Rationale: The correct answer is B: 'Despair'. In separation anxiety, the stage of despair is characterized by regression and withdrawal after the initial protest. The toddler's shift from intense crying to lying quietly with a blanket demonstrates this withdrawal behavior. Choice A, 'Denial', is incorrect as denial involves refusing to accept the reality of separation. Choice C, 'Mistrust', is incorrect as it relates to a lack of trust rather than the stage of separation anxiety described in the scenario. Choice D, 'Rejection', is incorrect as it does not reflect the behavior of the toddler in the scenario, which is more indicative of withdrawal and regression.

5. What behavior does the nurse anticipate when feeding a newborn with choanal atresia?

• A. Chokes during feeding
• B. Experiences swallowing challenges
• C. Lacks hunger cues
• D. Takes about half of the feeding

Correct answer: D

Rationale: When feeding a newborn with choanal atresia, the nurse can anticipate that the infant may take only part of the feeding before pausing for air. This is due to the fact that infants with choanal atresia struggle to breathe through their nose while feeding. Choice A is incorrect as choking typically involves a more severe airway obstruction. Choice B is incorrect because difficulty swallowing is not the primary concern in choanal atresia. Choice C is incorrect as the issue is not related to hunger cues but rather the physiological challenges associated with breathing while feeding.

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