Nursing Elites

1. Prior to discharge, the parents of a child with cystic fibrosis are demonstrating chest physiotherapy (CPT) that they will perform for their child at home. Which action requires intervention by the nurse?

• A. Plan to perform CPT when the child awakens in the morning.
• B. A cupped hand is used when percussing the lung field.
• C. A bronchodilator is administered before starting CPT.
• D. The child is placed in a supine position to begin percussion.

Correct answer: D

Rationale: The correct answer is D. Placing the child in a supine position to begin percussion is incorrect for chest physiotherapy (CPT). This position is not effective for CPT as it may lead to improper drainage of secretions. The child should be in an appropriate sitting or slightly reclined position to ensure proper lung drainage during CPT. Choices A, B, and C are all appropriate actions for chest physiotherapy. Performing CPT when the child awakens helps in clearing secretions, using a cupped hand during percussion is a proper technique to promote secretion movement, and administering a bronchodilator before CPT can help open up the airways for better clearance.

2. Following admission for cardiac catheterization, the nurse is providing discharge teaching to the parents of a 2-year-old toddler with tetralogy of Fallot. What instruction should the nurse give the parents if their child becomes pale, cool, and lethargic?

• A. Encourage oral electrolyte solution intake
• B. Assist the child to a recumbent position
• C. Contact their healthcare provider immediately
• D. Provide a quiet time by holding or rocking the toddler

Correct answer: C

Rationale: If a child with tetralogy of Fallot becomes pale, cool, and lethargic, these symptoms may indicate a hypoxic episode or worsening condition. It is crucial to contact the healthcare provider immediately for further evaluation and management to ensure the child's safety and well-being. Option A is incorrect because electrolyte solution intake is not the immediate action needed for these symptoms. Option B is incorrect as positioning alone may not address the underlying issue. Option D is incorrect as providing a quiet time is not appropriate if the child is experiencing concerning symptoms that require prompt medical attention.

3. A 10-year-old child is brought to the emergency department after falling from a bicycle and hitting their head. The nurse notes that the child is drowsy and has a headache. What is the nurse’s priority action?

• A. Perform a full neurological assessment
• B. Administer pain medication
• C. Allow the child to rest quietly
• D. Check the child's immunization status

Correct answer: A

Rationale: In a child who has fallen and hit their head, presenting with drowsiness and headache, the priority action for the nurse is to perform a full neurological assessment. This is crucial to evaluate the extent of the head injury and monitor for signs of increased intracranial pressure, which could indicate a more severe traumatic brain injury. Administering pain medication or allowing the child to rest quietly are not appropriate initial actions without first assessing the neurological status. Checking the child's immunization status is important for overall health but is not the priority in this acute situation.

4. The mother of an 11-year-old boy with juvenile arthritis tells the nurse, 'I really don't want my son to become dependent on pain medication, so I only allow him to take it when he is really hurting.' Which information is most important for the nurse to provide this mother?

• A. The child should be encouraged to rest when experiencing pain
• B. Encourage quiet activities such as reading as a pain distracter
• C. The use of hot baths can be used as an alternative to pain medication
• D. Giving pain medication around the clock helps control the pain

Correct answer: D

Rationale: It is crucial for the nurse to educate the mother that giving pain medication around the clock helps manage pain effectively and improves the child's quality of life. This approach ensures a more consistent level of pain relief and prevents the pain from becoming severe, which can be more challenging to manage. Choices A, B, and C do not address the importance of consistent pain management and may not provide adequate relief for the child's condition.

5. The nurse is assessing a 6-month-old infant. Which response requires further evaluation by the nurse?

• A. Has doubled birth weight.
• B. Turns head to locate sound.
• C. Plays peek-a-boo.
• D. Demonstrates startle reflex.

Correct answer: D

Rationale: At 6 months old, the startle reflex should diminish, so its persistence warrants further evaluation by the nurse. Choices A, B, and C are appropriate developmental milestones for a 6-month-old infant. By 6 months, infants typically double their birth weight, exhibit localization of sound by turning their head, and engage in interactive play like peek-a-boo.

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