Nursing Elites

1. During a follow-up clinical visit, a mother tells the nurse that her 5-month-old son, who had surgical correction for tetralogy of Fallot, has rapid breathing, often takes a long time to eat, and requires frequent rest periods. The infant is not crying while being held, and his growth is in the expected range. Which intervention should the nurse implement?

• A. Stimulate the infant to cry to produce cyanosis
• B. Auscultate the heart and lungs while holding the infant
• C. Evaluate the infant for failure to thrive
• D. Obtain a 12-lead electrocardiogram

Correct answer: B

Rationale: Auscultating the heart and lungs while the infant is held is the most appropriate intervention to assess his current condition. This action allows the nurse to gather important information regarding the cardiovascular and respiratory status of the infant, which is crucial in evaluating his post-surgical recovery and overall well-being. Option A is incorrect as stimulating the infant to cry intentionally is not necessary and could cause distress. Option C is incorrect as the infant's growth is within the expected range, indicating no signs of failure to thrive. Option D is incorrect as obtaining a 12-lead electrocardiogram is not the initial intervention needed in this situation; assessing the heart and lungs through auscultation is more immediate and informative.

2. A 7-year-old child with cystic fibrosis is admitted to the hospital with a respiratory infection. The nurse is teaching the child’s parents about the importance of chest physiotherapy (CPT). Which statement by the parents indicates they need further teaching?

• A. We should perform CPT before meals.
• B. CPT will help loosen mucus in the lungs.
• C. We should perform CPT right after the child eats.
• D. CPT is an important part of our child’s treatment.

Correct answer: C

Rationale: The correct answer is C. Chest physiotherapy should not be performed right after meals to avoid inducing vomiting. It should be done before meals or at least 1 hour after for effective mucus clearance and to prevent any potential complications like vomiting. Choice A is correct as performing CPT before meals helps in loosening mucus. Choice B is also correct as CPT is indeed helpful in loosening mucus in the lungs. Choice D is correct as CPT plays a crucial role in the treatment of cystic fibrosis.

3. A 15-year-old adolescent with anorexia nervosa is admitted to the hospital for severe weight loss. The nurse notes that the client has dry skin, brittle hair, and is severely underweight. What is the nurse’s priority intervention?

• A. Establish a therapeutic relationship with the client
• B. Monitor the client’s vital signs frequently
• C. Initiate a structured eating plan
• D. Provide education about healthy eating habits

Correct answer: C

Rationale: In this scenario, the priority intervention for the nurse is to initiate a structured eating plan. Anorexia nervosa is a serious eating disorder characterized by severe food restriction, which can lead to malnutrition and severe weight loss. By starting a structured eating plan, the nurse can ensure the client receives the necessary nutrition to begin the process of weight restoration and recovery. Monitoring vital signs is essential, but without addressing the nutrition deficiency, vital signs may not improve significantly. Establishing a therapeutic relationship is crucial for long-term care but may not address the immediate risk of malnutrition. Providing education about healthy eating habits is important but may not be effective initially due to the severity of the client's condition.

4. When developing a behavior modification program for an extremely aggressive 10-year-old boy, what should the nurse do first?

• A. Identify what activities, foods, and toys the child enjoys
• B. Assess the child's previous reactions to punishment
• C. Offer the child positive feedback
• D. Involve other children on the unit in describing the token system

Correct answer: A

Rationale: The first step in developing a behavior modification program for an extremely aggressive 10-year-old boy is to identify what activities, foods, and toys the child enjoys. Understanding the child's motivations is crucial in creating an effective behavior modification plan tailored to his interests and preferences, which can help in positively reinforcing desired behaviors.

5. A child who weighs 25 kg is receiving IV ampicillin 300 mg/kg/24 hours in equally divided doses every 4 hours. How many milligrams should the nurse administer to the child for each dose?

• A. 1875 mg
• B. 625 mg
• C. 2000 mg
• D. 1500 mg

Correct answer: A

Rationale: To calculate the dose for each administration, multiply the child's weight (25 kg) by the dose (300 mg/kg/24 hours) and divide by the number of doses per day (6, as doses are every 4 hours). This gives us (25 kg * 300 mg/kg / 24 hours) / 6 doses = 1875 mg. Therefore, the nurse should administer 1875 mg for each dose. Choice B, 625 mg, is incorrect as it does not consider the correct calculation based on the weight and prescribed dose. Choice C, 2000 mg, is incorrect as it is not derived from the correct dosage calculation. Choice D, 1500 mg, is incorrect as it does not reflect the accurate dosage calculation based on the weight of the child and the prescribed dose.

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