Nursing Elites

1. A young child has coarctation of the aorta. What does the nurse expect to identify when taking the child’s vital signs?

• A. A weak radial pulse
• B. An irregular heartbeat
• C. A bounding femoral pulse
• D. An elevated radial blood pressure

Correct answer: A

Rationale: In coarctation of the aorta, there is narrowing of the aorta leading to decreased blood flow distal to the constriction. This results in a weak or delayed femoral pulse and a relatively weaker radial pulse compared to the femoral pulse. An irregular heartbeat (choice B) is not a typical finding in coarctation of the aorta. A bounding femoral pulse (choice C) would not be expected due to the decreased blood flow beyond the constriction. An elevated radial blood pressure (choice D) is not a common characteristic of coarctation of the aorta; instead, blood pressure may be higher in the upper extremities compared to the lower extremities due to the constriction.

2. When administering IV fluids to a dehydrated infant, what intervention is most important at this time?

• A. Continuing the prescribed flow rate
• B. Monitoring the intravenous drop rate
• C. Calculating the total necessary intake
• D. Maintaining the fluid at body temperature

Correct answer: B

Rationale: Monitoring the intravenous drop rate is the most crucial intervention when administering IV fluids to a dehydrated infant. This ensures that the correct amount of fluids is being delivered to the infant at the appropriate rate. While continuing the prescribed flow rate (Choice A) may be important, it does not allow for real-time adjustments that may be necessary during the infusion. Calculating the total necessary intake (Choice C) should have been determined before initiating IV therapy. Maintaining the fluid at body temperature (Choice D) is important for patient comfort but is not as critical as ensuring the proper administration of fluids.

3. A 4-year-old fell from a third-story window and landed on her head. She is semiconscious with slow, irregular breathing and bleeding from her mouth. After performing a jaw-thrust maneuver with simultaneous stabilization of her head, what should you do next?

• A. Suction the oropharynx
• B. Insert a nasopharyngeal airway
• C. Initiate positive pressure ventilations
• D. Administer oxygen via mask

Correct answer: A

Rationale: In this scenario, the patient is experiencing airway compromise due to the fall and potential oropharyngeal obstruction from bleeding. Performing a jaw-thrust maneuver with head stabilization helps maintain the airway patency. The next step should be to suction the oropharynx to clear any blood or secretions, which can obstruct the airway and lead to aspiration. Inserting a nasopharyngeal airway may worsen bleeding or cause further injury to the patient's airway. Initiating positive pressure ventilations can be ineffective if the airway is not cleared first. Administering oxygen via mask is not the immediate priority; ensuring a patent airway by suctioning takes precedence.

4. During a vaccination drive at a well-child clinic, a nurse observes that a recently hired nurse is not wearing gloves. What should the nurse advise the newly hired nurse to do?

• A. Speak with the nurse manager regarding techniques.
• B. Put on gloves because standard precautions are required.
• C. Continue with the immunizations because gloves are not needed.
• D. Evaluate the child’s appearance to determine whether gloves are needed.

Correct answer: B

Rationale: The correct answer is B: "Put on gloves because standard precautions are required." Standard precautions are essential in healthcare settings to prevent the transmission of infections, and wearing gloves is a crucial part of these precautions during immunizations. Choice A is incorrect because speaking with the nurse manager about techniques does not address the immediate need for wearing gloves. Choice C is incorrect because gloves are indeed needed to prevent the spread of infections. Choice D is incorrect as evaluating the child's appearance is not a substitute for wearing gloves which are a basic infection control measure.

5. A 2-week-old infant is admitted with a tentative diagnosis of a ventricular septal defect. The parents report that their baby has had difficulty feeding since coming home after birth. What should the nurse consider before responding?

• A. Feeding problems are common in neonates.
• B. Inadequate sucking is not significant in the absence of cyanosis.
• C. Ineffective sucking and swallowing may be early indications of a heart defect.
• D. Many neonates retain mucus, which may interfere with feeding for several weeks.

Correct answer: C

Rationale: In this scenario, the nurse should consider that ineffective sucking and swallowing in a 2-week-old infant could be early signs of a heart defect such as a ventricular septal defect. This is crucial information as it can guide further assessment and management. Choice A is incorrect because while feeding problems can be common in neonates, in this case, the specific context of a suspected heart defect should be prioritized. Choice B is incorrect as inadequate sucking can indeed be significant, especially when considering potential underlying heart issues, regardless of the presence of cyanosis. Choice D is incorrect as while mucus retention can affect feeding, in this case, the focus should be on the possibility of a heart defect rather than a temporary issue like mucus interference.

Similar Questions