Nursing Elites

1. The healthcare provider assesses the vital signs of a 12-month-old infant with a respiratory infection and notes that the respiratory rate is 35 breaths/minute. Based on this finding, which action is most appropriate?

• A. Administer oxygen
• B. Document the findings
• C. Notify the healthcare provider
• D. Reassess the respiratory rate in 15 minutes

Correct answer: B

Rationale: Documenting the findings is the most appropriate action since a respiratory rate of 35 breaths per minute falls within the normal range for a 12-month-old infant. There is no immediate need for interventions such as administering oxygen or notifying the healthcare provider. Reassessing the respiratory rate in 15 minutes is unnecessary as the rate is within normal limits.

2. You have arrived for your shift on the children's ward and need to assess a 2-year-old who is accompanied by his father. Identify the appropriate strategy to successfully complete a focused assessment:

• A. Allow the child to inspect the equipment for faults before and during assessment
• B. Ask parent to leave room until assessment has been completed
• C. Perform traumatic or invasive procedures first
• D. Have the child sit in parents lap and request assistance if necessary

Correct answer: D

Rationale: Having the child sit in parent's lap can help reduce anxiety and allow for a more accurate assessment.

3. The nurse is preparing to administer erythromycin eye ointment to a newborn. The mother asks why this is necessary. What is the nurse's best response?

• A. It helps to prevent eye infections caused by bacteria in the birth canal.
• B. It protects the baby's eyes from bright lights in the delivery room.
• C. It prevents the development of jaundice.
• D. It helps the baby see more clearly after birth.

Correct answer: A

Rationale: Erythromycin eye ointment is administered to newborns to prevent eye infections caused by bacteria present in the birth canal. This ointment does not have a direct correlation with protecting the baby's eyes from bright lights, preventing jaundice, or improving the baby's vision clarity post-birth.

4. When evaluating a client's fluid intake and output record, how should fluid intake and urine output relate?

• A. Fluid intake should double the urine output
• B. Fluid intake should be approximately equal to the urine output
• C. Fluid intake should be half the urine output
• D. Fluid intake should be inversely proportional to the urine output

Correct answer: B

Rationale: In assessing a client's fluid intake and output record, it is essential for fluid intake to be approximately equal to the urine output. This balance indicates proper hydration and renal function. Deviations from this balance could signify potential issues that need further investigation and management.

5. You are caring for a 6-year-old child with a possible fractured arm and have reason to believe that the child was abused. How should you manage this situation?

• A. Inform the parents of your suspicions.
• B. Transport the child to the hospital regardless of the parents' wishes.
• C. Call the police and have the parents arrested.
• D. Advise the parents that the child needs to be transported.

Correct answer: D

Rationale: In cases where child abuse is suspected, the priority is the safety and well-being of the child. Advising the parents that the child needs to be transported for further evaluation and care is the appropriate initial step. This ensures that the child receives necessary medical attention while also addressing the suspicion of abuse through proper channels. It is essential to involve appropriate authorities and follow established procedures to protect the child and investigate any potential abuse further.

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