Nursing Elites

1. Following corrective surgery for hypertrophic pyloric stenosis (HPS), an infant is returned to the pediatric unit with an IV infusion in place. What is the priority nursing action?

• A. Apply adequate restraints.
• B. Administer a mild sedative.
• C. Assess the IV site for infiltration.
• D. Attach the nasogastric tube to wall suction.

Correct answer: C

Rationale: The priority nursing action after a corrective surgery for hypertrophic pyloric stenosis (HPS) is to assess the IV site for infiltration. This is crucial to ensure proper fluid administration and prevent complications such as extravasation or infiltration. Applying restraints (Choice A) is not indicated in this scenario and can compromise the infant's comfort and safety. Administering a mild sedative (Choice B) is not necessary and should only be done based on specific clinical indications. Attaching the nasogastric tube to wall suction (Choice D) may be important for certain conditions but is not the priority immediately post-surgery; assessing the IV site is more urgent to prevent potential complications related to IV therapy.

2. After instituting ordered measures to reduce the fever in a 3-year-old with fever and vomiting, what nursing action is most important for the nurse in the emergency department to take?

• A. Preventing shivering
• B. Restricting oral fluids
• C. Measuring output hourly
• D. Taking vital signs hourly

Correct answer: A

Rationale: Preventing shivering is crucial in this situation as it can increase the body temperature and counteract the effects of antipyretic measures aimed at reducing the fever. Shivering generates heat, potentially worsening the fever. Restricting oral fluids (Choice B) is not appropriate as fluid intake is important to prevent dehydration, especially in a child who has been vomiting. Measuring output hourly (Choice C) and taking vital signs hourly (Choice D) are important nursing actions but not as critical as preventing shivering in this scenario. Therefore, the most important nursing action is to prevent shivering to aid in fever reduction and management.

3. A nurse is evaluating a 3-year-old child’s developmental progress. The inability to perform which task indicates to the nurse that there is a developmental delay?

• A. Copying a square
• B. Hopping on one foot
• C. Catching a ball reliably
• D. Using a spoon effectively

Correct answer: A

Rationale: The correct answer is A: Copying a square. At 3 years old, children should be able to copy a square as part of their fine motor skill development. The inability to perform this task may indicate a developmental delay in fine motor skills. Choice B, hopping on one foot, typically develops around 4-5 years of age, so it is not a reliable indicator of a delay at 3. Choice C, catching a ball reliably, involves coordination skills that develop later in childhood, making it less relevant for a 3-year-old assessment. Choice D, using a spoon effectively, is more related to self-care and feeding skills rather than fine motor development, so it is not the best indicator of a developmental delay in this context.

4. A child with a diagnosis of leukemia is receiving chemotherapy. What is the most important nursing intervention?

• A. Monitor for signs of infection
• B. Monitor for signs of bleeding
• C. Monitor for signs of dehydration
• D. Monitor for signs of pain

Correct answer: A

Rationale: The correct answer is to monitor for signs of infection. When a child is undergoing chemotherapy, their immune system is compromised, making them more susceptible to infections. Monitoring for signs of infection is crucial to promptly identify and treat any potential infections. Choices B, C, and D are incorrect because although monitoring for bleeding, dehydration, and pain are important aspects of care, the priority for a child receiving chemotherapy is to prevent and detect infections due to their increased vulnerability.

5. The nurse is caring for an 8-year-old girl with an endocrine disorder involving the posterior pituitary gland. What care would the nurse expect to implement?

• A. Instructing the parents to report adverse reactions to the growth hormone treatment
• B. Teaching the parents how to administer desmopressin acetate
• C. Informing the parents that treatment stops when puberty begins
• D. Educating the parents to report signs of acute adrenal crisis

Correct answer: B

Rationale: In a child with a disorder of the posterior pituitary gland, desmopressin acetate is commonly used to manage the condition by replacing the antidiuretic hormone. Instructing the parents to administer desmopressin acetate correctly is essential for the child's treatment. The other options are incorrect because growth hormone treatment, stopping treatment at puberty, and reporting signs of acute adrenal crisis are not directly related to managing a disorder of the posterior pituitary gland.

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