Nursing Elites

1. During the admission procedure of a 6-year-old, the child states, 'I’m going to have an operation.' Which response is best for the nurse to provide to this child?

• A. Are you scared?
• B. We’re going to do everything we can to take very good care of you.
• C. Tell me what an operation is.
• D. I’m glad your mother told you why you were coming to the hospital.

Correct answer: B

Rationale: In this situation, the most appropriate response for the nurse is to provide reassurance and express care to alleviate the child's anxiety about the upcoming operation. By reassuring the child that everything will be done to take very good care of them, the nurse helps build trust and comfort, creating a positive and supportive environment for the child.

2. A 3-month-old with myelomeningocele and atonic bladder is catheterized every 4hrs to prevent urinary retention. The home health nurse notes that the child has developed episodes of sneezing, urticarial, watery eyes, and a rash in the diaper area. What action is most important for the nurse to take?

• A. Auscultate the lungs for respiratory pneumonia.
• B. Change to latex-free gloves when handling infant.
• C. Draw blood to analyze for streptococcal infection.
• D. Apply zinc oxide to perineum with each diaper change.

Correct answer: B

Rationale: Latex allergy is a concern in patients with myelomeningocele, so switching to latex-free gloves is important.

3. A pregnant woman comes to the prenatal clinic for an initial visit. In reviewing her childbearing history, the client indicates that she has delivered premature twins, one full-term baby, and has had no abortions. Which GTPAL should the LPN/LVN document in this client's record?

• A. 3-1-2-0-3.
• B. 4-1-2-0-3.
• C. 2-1-2-1-2.
• D. 3-1-1-0-3.

Correct answer: D

Rationale: The correct GTPAL for this client is 3-1-1-0-3. G (Gravida) is 3, indicating a total of 3 pregnancies. T (Term) is 1, representing 1 full-term delivery. P (Preterm) is 1, not 2 as mentioned in the question, as twins count as one pregnancy event. A (Abortions) is 0, and L (Living) is 3, indicating 3 living children (twins count as 1). Therefore, the correct answer is 3-1-1-0-3.

4. An unlicensed assistive personnel (UAP) reports to the charge nurse that a client who delivered a 7-pound infant 12 hours ago is reporting a severe headache. The client’s blood pressure is 110/70 mmHg, respiratory rate is 18 breaths/min, heart rate is 74 beats/min, and temperature is 98.6°F (37°C). What action should the charge nurse implement first?

• A. Notify the healthcare provider of the assessment findings.
• B. Administer analgesics as prescribed.
• C. Increase the client’s fluid intake.
• D. Monitor the client’s vital signs every hour.

Correct answer: A

Rationale: A severe headache post-delivery could indicate a serious condition such as preeclampsia or a spinal headache, which requires immediate medical attention. Notifying the healthcare provider of the assessment findings allows for prompt evaluation and appropriate management of the client's condition.

5. The client is 30 weeks pregnant and experiencing preterm labor. Which medication should the nurse anticipate administering to promote fetal lung maturity?

• A. Betamethasone (Celestone).
• B. Magnesium sulfate.
• C. Terbutaline (Brethine).
• D. Ampicillin.

Correct answer: A

Rationale: Betamethasone (Celestone) is the medication of choice to promote fetal lung maturity in cases of preterm labor. It helps accelerate surfactant production in the fetal lungs, reducing the risk of respiratory distress syndrome. Administering betamethasone to the mother can improve the baby's lung function and overall outcome if preterm birth occurs. Magnesium sulfate is commonly used to prevent seizures in preeclampsia or eclampsia. Terbutaline is a tocolytic agent used to suppress preterm labor contractions. Ampicillin is an antibiotic used for various bacterial infections but does not promote fetal lung maturity.

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