Nursing Elites

1. The caregiver discovers a 6-month-old infant unresponsive and calls for help. After opening the airway and finding the infant is still not breathing, what action should the caregiver take?

• A. Palpate femoral pulse and check for regularity.
• B. Deliver cycles of 30 chest compressions and 2 breaths.
• C. Give two breaths that make the chest rise.
• D. Feel the carotid pulse and check for adequate breathing.

Correct answer: C

Rationale: Providing two breaths that make the chest rise is the correct action in this situation. This helps to deliver oxygen to the infant's lungs and body, which is crucial in a situation where the infant is not breathing. Chest rise indicates successful ventilation, and it is an essential step in pediatric resuscitation, especially for infants. Choices A, B, and D are incorrect because palpating the femoral pulse, delivering chest compressions, and feeling the carotid pulse are not the initial actions to take when an infant is not breathing. The priority is to provide effective breaths to establish ventilation.

2. Which nursing intervention is most important to include in the plan of care for a child with acute glomerulonephritis?

• A. Encourage fluid intake.
• B. Promote complete bed rest.
• C. Weigh the child daily.
• D. Administer vitamin supplements.

Correct answer: C

Rationale: Weighing the child daily is crucial in managing a child with acute glomerulonephritis as it helps in monitoring fluid retention, which is a key concern in this condition. Daily weight monitoring allows healthcare providers to assess changes in fluid status and adjust treatment accordingly. It is an essential component of the care plan to ensure the child's health status is closely monitored during the management of acute glomerulonephritis. Encouraging fluid intake (Choice A) is generally beneficial but may not be the priority in this case where fluid retention needs close monitoring. Promoting complete bed rest (Choice B) can be important but may not be the most critical intervention. Administering vitamin supplements (Choice D) may not directly address the immediate concerns related to fluid retention in acute glomerulonephritis.

3. What is the best response for the nurse when a 2-year-old boy begins to cry as the mother starts to leave?

• A. Let me read this book to you.
• B. Two-year-olds usually stop crying the minute the parent leaves.
• C. Now be a big boy. Mommy will be back soon.
• D. Let's wave bye-bye to mommy.

Correct answer: D

Rationale: The best response for the nurse in this situation is to help the child understand that the separation is temporary. Waving bye-bye to mommy can be reassuring to the child and make the separation process easier. It acknowledges the child's feelings while providing a positive and comforting interaction. Choice A may distract the child temporarily but doesn't address the underlying issue of separation anxiety. Choice B is inaccurate as children may continue to cry even after the parent leaves. Choice C diminishes the child's emotions and doesn't offer a supportive approach.

4. A child who is admitted to the hospital with anemia is anxious, fearful, and hyperventilating. The nurse anticipates the child developing which acid-base imbalance?

• A. Metabolic acidosis
• B. Respiratory acidosis
• C. Respiratory alkalosis
• D. Metabolic alkalosis

Correct answer: C

Rationale: In this scenario, the child is hyperventilating, which leads to excessive loss of carbon dioxide. This loss of carbon dioxide causes respiratory alkalosis due to a decrease in the partial pressure of carbon dioxide in the blood. Therefore, the correct answer is respiratory alkalosis. Choices A, B, and D are incorrect. Metabolic acidosis is characterized by a decrease in pH and bicarbonate levels due to conditions like kidney disease. Respiratory acidosis is caused by retention of carbon dioxide, leading to an increase in the partial pressure of carbon dioxide. Metabolic alkalosis results from a loss of acid or an increase in bicarbonate levels.

5. The nurse is caring for a 4-year-old child who is hospitalized with pneumonia. The child is receiving IV antibiotics and oxygen therapy. The nurse notes that the child’s respiratory rate is 40 breaths per minute, and the oxygen saturation is 92%. What is the nurse’s priority action?

• A. Increase the child’s oxygen flow rate
• B. Notify the healthcare provider
• C. Encourage the child to take deep breaths
• D. Auscultate the child’s lung sounds

Correct answer: D

Rationale: In this scenario, the child is hospitalized with pneumonia, receiving IV antibiotics and oxygen therapy. With a high respiratory rate and decreased oxygen saturation, auscultating the child’s lung sounds is the priority action. This assessment can provide crucial information about the child’s respiratory status, such as the presence of adventitious sounds or decreased air entry, which can guide further interventions and help in evaluating the effectiveness of the current treatments. Increasing the oxygen flow rate may not address the underlying issue causing the decreased oxygen saturation. Notifying the healthcare provider can be necessary but auscultating lung sounds should be done first to gather more information. Encouraging the child to take deep breaths is important for respiratory function but should not be the immediate priority in this situation.

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