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. A postpartum client is being discharged. The nurse should include which information about postpartum depression?

• A. It can occur at any time postpartum
• B. It is a serious condition that requires attention
• C. It can affect the ability to care for the newborn
• D. It may necessitate medical intervention

Correct answer: C

Rationale: Postpartum depression is a serious condition that can impact a mother's ability to care for her newborn. It is crucial for healthcare providers to educate clients about the signs and symptoms of postpartum depression, as it may necessitate medical intervention to ensure the well-being of both the mother and the newborn.

3. Justine is admitted to the pediatric unit due to the occurrence of diabetic ketoacidosis signaling a new diagnosis of diabetes. The diabetes team explores the cause of the episode and takes steps to prevent a recurrence. Diabetic ketoacidosis (DKA) results from an excessive accumulation of which of the following?

• A. Sodium bicarbonate from renal compensation
• B. Potassium from cell death
• C. Glucose from carbohydrate metabolism
• D. Ketone bodies from fat metabolism

Correct answer: D

Rationale: Diabetic ketoacidosis (DKA) results from the excessive accumulation of ketone bodies from fat metabolism. During DKA, there is a lack of insulin leading to the breakdown of fat stores into fatty acids and their subsequent conversion into ketone bodies. These ketone bodies accumulate in the blood, leading to metabolic acidosis and the characteristic symptoms of DKA.

4. You are treating a 5-year-old child who has had severe diarrhea and vomiting for 3 days and is now showing signs of shock. Supplemental oxygen has been given, and you have elevated his lower extremities. En route to the hospital, you note that his work of breathing has increased. You should:

• A. begin positive-pressure ventilations and reassess the child.
• B. lower the extremities and reassess the child.
• C. listen to the lungs with a stethoscope for abnormal breath sounds.
• D. insert a nasopharyngeal airway and increase the oxygen flow.

Correct answer: B

Rationale: When the work of breathing increases after elevating the legs, it is important to lower the extremities. Elevating the lower extremities in a child with signs of shock can worsen the condition by reducing venous return to the heart. Lowering the extremities can help improve venous return and potentially alleviate the increased work of breathing.

5. When teaching a new mother how to perform perineal care, which instruction should be included?

• A. Use a front-to-back motion when cleaning the perineal area
• B. Use a peri-bottle filled with warm water after each voiding
• C. Avoid using any cleansing solution on the perineal area
• D. Apply powder to the perineal area to keep it dry

Correct answer: B

Rationale: Using a peri-bottle filled with warm water after each voiding is essential for proper perineal care as it helps cleanse the area without causing irritation and promotes healing. It is important to avoid using a back-to-front motion to prevent introducing bacteria into the urethra, and using powder may increase the risk of infection. Cleansing solutions specifically formulated for perineal care may be recommended but should be used under healthcare provider guidance.

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