Nursing Elites

1. Fred is a 12-year-old boy diagnosed with pneumococcal pneumonia. Which of the following would Nurse Nica expect to assess?

• A. Mild cough
• B. Slight fever
• C. Chest pain
• D. Bulging fontanel

Correct answer: C

Rationale: Chest pain is a common symptom seen in patients with pneumococcal pneumonia. It can result from inflammation of the pleura or irritation of the diaphragm due to the infection. While cough and fever are also common symptoms, chest pain is particularly significant in pneumonia cases as it can be a distressing symptom for the patient and may indicate complications or severity of the infection. Bulging fontanel, on the other hand, is more indicative of conditions affecting infants and is not typically associated with pneumococcal pneumonia in a 12-year-old boy.

2. The healthcare provider is assessing a newborn who is 2 hours old. Which finding requires immediate intervention?

• A. Acrocyanosis
• B. Respiratory rate of 60 breaths per minute
• C. Grunting with nasal flaring
• D. Heart rate of 140 beats per minute

Correct answer: C

Rationale: Grunting with nasal flaring is a concerning sign of respiratory distress in a newborn that can indicate inadequate oxygenation. This finding requires immediate intervention to ensure the newborn's respiratory status is stabilized and to prevent further complications. Prompt assessment and appropriate intervention are crucial in such cases to prevent respiratory compromise and potential deterioration. Acrocyanosis, which is bluish discoloration of the extremities, is a common finding in newborns and usually resolves on its own. A respiratory rate of 60 breaths per minute and a heart rate of 140 beats per minute are within normal ranges for a newborn and do not indicate immediate intervention is needed.

3. What is the MOST appropriate method for assessing a small child's level of responsiveness?

• A. Palpate for a radial pulse.
• B. Shout at the child to see if they respond.
• C. Ask the parent about the child's level of responsiveness.
• D. Tap the child and shout, 'Are you okay?'

Correct answer: D

Rationale: When assessing a small child's level of responsiveness, the most appropriate method is to tap the child and shout, 'Are you okay?' This approach is more likely to elicit a response from the child, providing a direct assessment of their level of consciousness and responsiveness. Palpating for a radial pulse (Choice A) is not the most direct method for assessing responsiveness in a child. Shouting at the child (Choice B) may startle them and not provide an accurate assessment. Asking the parent (Choice C) does not directly evaluate the child's responsiveness.

4. What is the most appropriate technique to use when explaining a central line dressing change to a preschool-age client?

• A. Show a picture of the procedure in a book.
• B. Explain the procedure with clear instructions.
• C. Let the child perform a dressing change on a doll.
• D. None of the above.

Correct answer: C

Rationale: The most appropriate technique to use when explaining a central line dressing change to a preschool-age client is to let the child perform a dressing change on a doll. Preschool-age children learn best through play and hands-on activities. Allowing the child to practice on a doll helps them understand the procedure in a non-threatening and interactive way. This technique can reduce anxiety, increase cooperation, and enhance the child's understanding of the dressing change process. Choices A and B do not provide a hands-on approach, which is crucial for preschool-age children. Choice D is incorrect as providing an interactive experience is more effective than just showing pictures or giving verbal instructions.

5. The healthcare provider is preparing to administer Rh immune globulin (RhoGAM) to a postpartum client. This medication is indicated for:

• A. Rh-negative individuals with Rh-positive infants
• B. Rh-positive individuals with Rh-negative infants
• C. All individuals regardless of Rh status
• D. Individuals with a history of Rh incompatibility

Correct answer: A

Rationale: Rh immune globulin (RhoGAM) is administered to Rh-negative individuals who have given birth to Rh-positive infants to prevent Rh sensitization. When an Rh-negative individual gives birth to an Rh-positive infant, there is a risk of the mother developing antibodies against the Rh-positive blood cells, which can lead to hemolytic disease of the newborn in subsequent pregnancies. Rh immune globulin is given to prevent this sensitization in Rh-negative individuals who deliver Rh-positive infants.

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