Nursing Elites

1. A pediatric client is admitted to the emergency department with a traumatic brain injury (TBI) that caused a loss of consciousness. The last set of vital signs showed heart rate 48, blood pressure (BP) 148/74 mmHg, respiratory rate 28 and irregular. What does the nurse suspect based on these data?

• A. Spinal cord injury
• B. Increased intracranial pressure
• C. Typical for sleep
• D. Improvement

Correct answer: B

Rationale: The vital signs of bradycardia, hypertension, and irregular respirations indicate increased intracranial pressure. Bradycardia (heart rate of 48), hypertension (blood pressure of 148/74 mmHg), and irregular respirations are typical signs of increased intracranial pressure in a pediatric client with a traumatic brain injury and loss of consciousness.

2. A nurse is planning care for a 2-month-old infant who is postoperative following surgical repair of a cleft lip. Which of the following actions should the nurse take?

• A. Position the infant on his abdomen
• B. Cleanse the incision site with hydrogen peroxide
• C. Offer the infant a pacifier
• D. Keep the infant's elbow restrained

Correct answer: D

Rationale:

3. When teaching a parent of a child with hemophilia, which of the following instructions should the nurse include?

• A. Administer aspirin for pain.
• B. Avoid administering NSAIDs.
• C. Restrict physical activities.
• D. Apply heat to joints.

Correct answer: B

Rationale: The correct answer is B: 'Avoid administering NSAIDs.' Hemophilia is a condition where blood does not clot properly. NSAIDs (Nonsteroidal Anti-Inflammatory Drugs) can increase the risk of bleeding in individuals with hemophilia. Therefore, it is crucial for the parent to avoid giving their child NSAIDs for pain management to prevent exacerbating bleeding tendencies. Choice A is incorrect because aspirin, like NSAIDs, can also increase the risk of bleeding. Choice C is incorrect because physical activities should not be restricted but rather managed to prevent injuries that could lead to bleeding. Choice D is incorrect because applying heat to joints can worsen bleeding in individuals with hemophilia.

4. As a result of opioid administration, a child's respirations are slow and shallow. Which should the nurse anticipate when assessing the child's arterial blood gas?

• A. Increased PCO2 and respiratory acidosis
• B. Decreased PCO2 and respiratory alkalosis
• C. Low pH and low PCO2
• D. High pH and high PCO2

Correct answer: A

Rationale: When a child's respirations are slow and shallow due to opioid administration, it results in hypoventilation. This leads to retaining carbon dioxide, indicated by an increased PCO2 level on arterial blood gas analysis, and subsequently causes respiratory acidosis due to the buildup of CO2 in the blood. Therefore, choice A, 'Increased PCO2 and respiratory acidosis,' is the correct answer. Choices B, C, and D are incorrect because slow and shallow respirations would not lead to decreased PCO2 or respiratory alkalosis (choice B), low pH and low PCO2 (choice C), or high pH and high PCO2 (choice D).

5. During a home care visit for an infant diagnosed with gastroesophageal reflux, which parental action observed requires intervention by the nurse?

• A. The infant's formula is mixed with rice cereal.
• B. The mother positions the infant in a high Fowler position while feeding.
• C. After feeding, the infant is placed in a car seat.
• D. The mother administers ranitidine (Zantac) to the infant using a syringe.

Correct answer: C

Rationale: Placing an infant diagnosed with gastroesophageal reflux in a car seat after feeding can increase the risk of reflux and aspiration. The semi-upright or high Fowler position is recommended to help reduce reflux symptoms during feeding. Adding rice cereal to formula can help thicken it and reduce reflux episodes. Administering ranitidine using a syringe is a common method of oral medication administration. Therefore, the action of placing the infant in a car seat after feeding is the one that requires intervention due to the increased risk it poses.

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