Nursing Elites

1. 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.

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 priority action for a 2-year-old child with croup presenting with a barking cough and stridor?

• A. Administer a corticosteroid
• B. Obtain a throat culture
• C. Administer nebulized epinephrine
• D. Place the child in an upright position

Correct answer: C

Rationale: The priority action for a 2-year-old child with croup and stridor is to administer nebulized epinephrine. Nebulized epinephrine helps reduce airway swelling, alleviate symptoms, and improve breathing by causing vasoconstriction and reducing upper airway edema. Administering a corticosteroid may be done but is not the priority in this scenario. Obtaining a throat culture is not necessary for the immediate management of croup. Placing the child in an upright position can aid in breathing but is not the priority action when the child is presenting with stridor.

4. The caregiver is caring for a 3-year-old child with a diagnosis of gastroenteritis. The child has had several episodes of vomiting and diarrhea over the past 24 hours. What is the caregiver's priority assessment?

• A. Monitor the child's weight
• B. Assess the child's hydration status
• C. Evaluate the child's nutritional intake
• D. Check the child's temperature

Correct answer: B

Rationale: The correct answer is B: Assess the child's hydration status. In children with gastroenteritis, assessing hydration status is crucial as they are at risk of dehydration due to vomiting and diarrhea. Monitoring hydration helps prevent complications and guides appropriate interventions to maintain the child's fluid balance. Monitoring the child's weight (Choice A) is not the priority in this situation compared to assessing hydration status. Evaluating nutritional intake (Choice C) is important but not the priority when the child is at risk of dehydration. Checking the child's temperature (Choice D) is relevant but not the priority over assessing hydration status in a child with gastroenteritis.

5. A two-year-old child with heart failure is admitted for replacement of a graft for coarctation of the aorta. Prior to administering the next dose of digoxin (Lanoxin), the nurse obtains an apical heart rate of 128 bpm. What action should the nurse take?

• A. Determine the pulse deficit.
• B. Administer the scheduled dose.
• C. Calculate the safe dose range.
• D. Review the serum digoxin level.

Correct answer: B

Rationale: Administering the scheduled dose is appropriate in this scenario as the heart rate of 128 bpm falls within the acceptable range for a two-year-old child with heart failure. It indicates that the child may benefit from the therapeutic effects of digoxin. Monitoring the heart rate closely after administration is essential to ensure the medication's effectiveness and safety. Determining the pulse deficit (Choice A) is not necessary in this situation as the heart rate is within the acceptable range. Calculating the safe dose range (Choice C) is not needed since the heart rate is already within the expected parameters. Reviewing the serum digoxin level (Choice D) is not the immediate action required in this case where the heart rate is within the normal range.

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