Nursing Elites

1. A mother reports to the nurse at the pediatric clinic that her toddler has had a fever and sore throat for the past two days. The nurse observes several swollen red spots on the child's body, some of which are fluid-filled blisters. What action should the nurse take?

• A. Obtain a fluid culture from the blisters
• B. Administer a fever-reducing medication
• C. Cover the draining vesicles with a dressing
• D. Implement transmission precautions

Correct answer: D

Rationale: The presence of swollen red spots and fluid-filled blisters may indicate a contagious condition. Implementing transmission precautions is crucial to prevent the spread of the infection to others in the clinic setting.

2. What information should be reinforced with the parents about introducing solid foods to their infant?

• A. Begin with one tablespoon of the food.
• B. Introduce each food 4 to 7 days apart.
• C. Mix the new food with rice cereal.
• D. Remove foods when the infant refuses them.

Correct answer: B

Rationale: The correct answer is B. Introducing solid foods 4 to 7 days apart is crucial as it allows time to identify any allergic reactions or intolerances to specific foods. This gradual introduction helps parents monitor their infant's response to new foods and pinpoint any potential issues, ensuring the infant's safety and well-being. Choices A, C, and D are incorrect because starting with one tablespoon of the food, mixing new food with rice cereal, and removing foods when the infant refuses them are not recommended practices for introducing solid foods to infants.

3. What suggestion should the nurse provide to prevent diaper rash in a 4-month-old infant as requested by the mother?

• A. Generously powder the baby's diaper area with talcum powder at each diaper change to promote dryness.
• B. Wash the diaper area every 2 hours with soap and water to help prevent skin breakdown.
• C. Use a barrier cream, such as zinc oxide, which does not have to be completely removed with each diaper change.
• D. Place a cloth diaper inside the disposable diaper for overnight periods when increased wearing time is likely.

Correct answer: C

Rationale: Using a barrier cream like zinc oxide forms a protective layer on the skin, creating a barrier against irritants and moisture, thus helping to prevent diaper rash. Unlike other options, barrier creams do not need to be completely removed at each diaper change, allowing the skin to remain protected between changes.

4. A 12-year-old male is brought to the clinic after falling during a skateboarding trick. The child's vital signs are heart rate 135 beats/minute, respirations 20 breaths/minute, and blood pressure 90/60. Which finding should the practical nurse report to the healthcare provider immediately?

• A. The client complains of his back being sore.
• B. Capillary refill is less than 2 seconds.
• C. Blood pressure is 94/68.
• D. Peripheral pulses are weak and rapid.

Correct answer: D

Rationale: In this scenario, the 12-year-old male with a heart rate of 135 beats/minute, respirations of 20 breaths/minute, and blood pressure of 90/60 after falling during a skateboarding trick exhibits signs of shock. Weak and rapid peripheral pulses are concerning as they may indicate decreased cardiac output and tissue perfusion, which are signs of shock. This finding should be reported to the healthcare provider immediately for further evaluation and intervention to prevent potential complications. The other choices are less urgent. Complaints of back soreness (choice A) could be related to musculoskeletal injury. Capillary refill less than 2 seconds (choice B) is within the normal range, indicating adequate peripheral perfusion. A blood pressure of 94/68 (choice C) is slightly higher than the initial reading and may be compensatory in response to the fall and shock state.

5. 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.

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