Nursing Elites

1. A healthcare professional is reviewing the clinical records of infants and children with cardiac disorders who developed heart failure. What did the healthcare professional determine is the last sign of heart failure?

• A. Tachypnea
• B. Tachycardia
• C. Peripheral edema
• D. Periorbital edema

Correct answer: C

Rationale: Peripheral edema is often the last sign of heart failure in infants and children as it indicates significant fluid retention and circulatory compromise. Tachypnea (Choice A) and tachycardia (Choice B) are early signs of heart failure due to the body's compensatory mechanisms. Periorbital edema (Choice D) can occur in heart failure but is not typically the last sign; it is more commonly associated with renal or hepatic dysfunction.

2. A child with a diagnosis of gastroenteritis is admitted to the hospital. What is the priority nursing intervention?

• A. Monitoring fluid and electrolyte balance
• B. Encouraging regular exercise
• C. Administering antipyretics
• D. Administering antibiotics

Correct answer: A

Rationale: The correct answer is monitoring fluid and electrolyte balance. Gastroenteritis is characterized by inflammation of the gastrointestinal tract leading to diarrhea and vomiting, which can result in dehydration and electrolyte imbalances. Therefore, the priority nursing intervention is to monitor and maintain the child's fluid and electrolyte balance to prevent complications. Encouraging regular exercise (Choice B) may not be appropriate initially for a child with gastroenteritis who needs rest and fluid replacement. Administering antipyretics (Choice C) is not the priority unless the child has a fever. Administering antibiotics (Choice D) is not indicated for viral gastroenteritis, which is the most common cause of the condition.

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

• A. Provide small, frequent feedings
• B. Administer antibiotics
• C. Maintain strict isolation
• D. Elevate the head of the bed

Correct answer: D

Rationale: Elevating the head of the bed is crucial in the care plan for an infant with RSV as it helps improve breathing by facilitating better airflow and drainage of secretions. This position can also enhance comfort and reduce respiratory distress. Providing small, frequent feedings (Choice A) is generally beneficial for infants but is not specific to managing RSV. Administering antibiotics (Choice B) is not indicated for RSV as it is caused by a virus, and antibiotics are ineffective against viral infections. Maintaining strict isolation (Choice C) is important to prevent the spread of contagious infections but is not a direct intervention for improving the infant's respiratory status in RSV.

4. The nurse is caring for a 10-year-old with Duchenne muscular dystrophy. As part of the plan of care, the nurse focuses on maintaining his cardiopulmonary function. Which intervention would the nurse implement to best promote maximum chest expansion?

• A. Deep-breathing exercises
• B. Upright positioning
• C. Coughing
• D. Chest percussion

Correct answer: B

Rationale: Upright positioning is the most appropriate intervention to promote maximum chest expansion in a child with Duchenne muscular dystrophy. By keeping the child in an upright position, lung expansion is maximized, which improves breathing efficiency. Deep-breathing exercises may help with overall lung function but do not directly promote chest expansion. Coughing and chest percussion are more related to airway clearance and do not specifically address maximizing chest expansion.

5. The healthcare professional is developing a teaching plan for a child who is to have their cast removed. What instruction would the professional most likely include?

• A. Applying petroleum jelly to the dry skin.
• B. Rubbing the skin vigorously to remove the dead skin.
• C. Soaking the area in warm water every day.
• D. Washing the skin with diluted peroxide and water.

Correct answer: C

Rationale: Soaking the area in warm water is the most appropriate instruction for a child who is having their cast removed. This method helps to gently remove dead skin without causing irritation. Applying petroleum jelly to dry skin (Choice A) is not recommended as it may not effectively aid in the removal of dead skin. Rubbing the skin vigorously (Choice B) can lead to skin irritation and should be avoided. Washing the skin with diluted peroxide and water (Choice D) may be too harsh, causing unnecessary irritation to the skin post-cast removal.

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