Nursing Elites

1. An adolescent female who comes to the school clinic is reluctant to confide her concerns to the practical nurse (PN). The PN tells the teen that confidentiality and privacy are maintained unless a life-threatening situation arises. Which principle supports the PN's response?

• A. The adolescent should be encouraged to seek help outside of the school clinic.
• B. Disclosures from the adolescent should be kept confidential.
• C. Honest information ensures establishing a trusting relationship.
• D. Minor adolescents should not be encouraged to disclose private concerns.

Correct answer: C

Rationale: The correct principle supporting the practical nurse's response is that honest information ensures establishing a trusting relationship. By assuring confidentiality and privacy to the adolescent unless there is a life-threatening situation, the practical nurse fosters an environment where the teen feels safe to share their concerns openly. This approach helps build trust, encouraging effective communication and support for the adolescent's well-being. Choices A, B, and D are incorrect because encouraging seeking help outside the school clinic, keeping disclosures confidential, and discouraging minor adolescents from sharing private concerns do not address the immediate need to build trust and ensure the well-being of the adolescent in a school setting.

2. A child with pertussis is receiving azithromycin (Zithromax Injection) IV. Which intervention is most important for the nurse to include in the child's plan of care?

• A. Obtain vital signs to monitor for fluid overload
• B. Change IV site dressing every 3 days and as needed
• C. Monitor for signs of facial swelling or urticaria
• D. Assess for abdominal pain and vomiting

Correct answer: C

Rationale: When administering azithromycin IV, monitoring for signs of an allergic reaction, such as facial swelling or urticaria, is crucial. This helps in early detection of potential adverse reactions and ensures prompt intervention to prevent complications associated with the medication. The other options are not directly related to the administration of azithromycin IV in this scenario. Monitoring for fluid overload would be more relevant for fluid administration, changing IV site dressing is important but not the priority in this case, and assessing for abdominal pain and vomiting may be important but not as critical as monitoring for signs of an allergic reaction.

3. The nurse finds a 6-month-old infant unresponsive and calls for help. After opening the airway and finding the XXXX, the infant is still not breathing. What action should the nurse take next?

• A. Palpate the femoral pulse and check for regularity.
• B. Deliver cycles of 30 chest compressions and 2 breaths.
• C. Give two breaths that make the chest rise.
• D. Feel the carotid pulse and check for adequate breathing.

Correct answer: C

Rationale: In a scenario where a 6-month-old infant is unresponsive and not breathing after the airway is open, giving two breaths that make the chest rise is the appropriate action. This helps deliver oxygen to the infant's lungs and can help initiate breathing. Chest compressions are not recommended for infants as the first step in resuscitation. Checking pulses like the femoral or carotid pulse is not the priority when an infant is not breathing, as providing oxygen through breaths is essential.

4. A 10-year-old child is being discharged after being admitted for status asthmaticus. Which instruction is most important for the nurse to include in the discharge teaching?

• A. Use a peak flow meter daily to monitor asthma control
• B. Avoid exposure to known allergens
• C. Continue taking asthma medications as prescribed
• D. Seek emergency care if symptoms worsen

Correct answer: A

Rationale: Using a peak flow meter daily is crucial as it helps monitor asthma control by measuring how well the child's lungs are functioning. This monitoring can indicate when intervention is needed before symptoms worsen or become severe, allowing for timely management of asthma exacerbations.

5. The nurse is caring for a 3-year-old child who has been recently diagnosed with cystic fibrosis. Which discharge instruction by the nurse is most important to promote pulmonary function?

• A. Chest physiotherapy should be performed before meals and at bedtime
• B. Cough suppressants can be used up to four times a day for relief
• C. Oxygen should be given through a nasal cannula between 4-6 L/min
• D. Exercise is discouraged in order to preserve pulmonary vital capacity

Correct answer: B

Rationale: In cystic fibrosis, thick mucus obstructs the airways, making it difficult to clear from the lungs. Cough suppressants can help reduce the discomfort associated with persistent coughing, allowing the child to cough more effectively to clear the mucus, thus promoting pulmonary function. Chest physiotherapy, not exercise, helps mobilize the mucus. Oxygen therapy may be needed but is not the most important for promoting pulmonary function in this case.

Similar Questions