Nursing Elites

1. A nurse is caring for an infant with a tentative diagnosis of hypertrophic pyloric stenosis (HPS). What is most important for the nurse to assess?

• A. Quality of the cry
• B. Signs of dehydration
• C. Coughing up feedings
• D. Characteristics of the stool

Correct answer: B

Rationale: The correct answer is B: Signs of dehydration. Infants with hypertrophic pyloric stenosis (HPS) are at high risk of dehydration due to frequent vomiting. Assessing for signs of dehydration, such as decreased urine output, dry mucous membranes, and sunken fontanelles, is crucial for early intervention and management. Choices A, C, and D are not the most critical assessments for HPS. The quality of the cry (choice A) may not provide as much relevant information in this case. Coughing up of feedings (choice C) may be a symptom but is not as crucial as assessing for dehydration. Characteristics of the stool (choice D) are important but assessing for signs of dehydration takes precedence due to the immediate risk it poses to the infant's health.

2. A 2-year-old child with a diagnosis of hemophilia is admitted to the hospital. What should the nurse include in the care plan?

• A. Encourage participation in contact sports
• B. Use a soft toothbrush for oral care
• C. Administer nonsteroidal anti-inflammatory drugs
• D. Administer aspirin for pain

Correct answer: B

Rationale: Using a soft toothbrush helps to prevent bleeding in a child with hemophilia.

3. An infant is admitted to the neonatal intensive care unit (NICU) with exstrophy of the bladder. What covering should the nurse use to protect the exposed area?

• A. Loose diaper
• B. Dry gauze dressing
• C. Moist sterile dressing
• D. Petroleum jelly gauze pad

Correct answer: C

Rationale: In cases of exstrophy of the bladder, a moist sterile dressing is the most appropriate choice to protect the exposed bladder tissue. Moist sterile dressings help maintain a clean environment, prevent infection, and promote healing. A loose diaper (Choice A) may not provide adequate protection and may lead to contamination. Dry gauze dressing (Choice B) could adhere to the wound and cause trauma upon removal. Petroleum jelly gauze pad (Choice D) is not ideal as it may not provide the necessary barrier against infection and could potentially cause irritation.

4. During an assessment, a nurse is examining the skin of a child with cellulitis. What would the nurse expect to find?

• A. Red, raised hair follicles
• B. Warmth at skin disruption site
• C. Papules progressing to vesicles
• D. Honey-colored exudate

Correct answer: B

Rationale: The correct answer is B: 'Warmth at skin disruption site.' Cellulitis is characterized by localized warmth at the site of skin disruption, which indicates an infection. Choice A, 'Red, raised hair follicles,' is more typical of folliculitis. Choice C, 'Papules progressing to vesicles,' is suggestive of conditions like herpes simplex virus infections. Choice D, 'Honey-colored exudate,' is associated with impetigo, not cellulitis. When assessing cellulitis, nurses should primarily look for warmth, erythema, edema, and tenderness at the affected site.

5. What is the priority intervention for a child with acute laryngotracheobronchitis upon admission?

• A. Pad the side rails of the crib.
• B. Arrange for a quiet, cool room.
• C. Place a tracheotomy set at the bedside.
• D. Obtain a recliner for a parent to stay.

Correct answer: C

Rationale: The correct priority intervention for a child with acute laryngotracheobronchitis is to place a tracheotomy set at the bedside. Acute laryngotracheobronchitis can lead to airway obstruction, making it essential to have the equipment readily available in case of emergency. Padding the side rails, arranging for a quiet room, or obtaining a recliner for a parent are not the immediate priorities in managing a child with this condition.

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