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. The healthcare provider is assessing an infant with pyloric stenosis. Which pathophysiological mechanism is the most likely consequence of this infant's clinical picture?

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

Correct answer: A

Rationale: Pyloric stenosis leads to obstruction at the outlet of the stomach, causing frequent vomiting and loss of stomach acids. This results in a loss of hydrochloric acid and hydrogen ions, leading to metabolic alkalosis due to an increase in serum bicarbonate levels. Therefore, the correct answer is metabolic alkalosis. Choice B, respiratory acidosis, is incorrect as it is not typically associated with pyloric stenosis. Choice C, metabolic acidosis, is incorrect because the loss of stomach acids in pyloric stenosis leads to metabolic alkalosis, not acidosis. Choice D, respiratory alkalosis, is also incorrect as it is not the usual consequence of pyloric stenosis.

3. What intervention should the nurse implement first for a male toddler brought to the emergency center approximately three hours after swallowing tablets from his grandmother's bottle of digoxin (Lanoxin)?

• A. Administer activated charcoal
• B. Prepare gastric lavage
• C. Obtain a 12-lead electrocardiogram
• D. Give IV digoxin immune fab (Digibind)

Correct answer: A

Rationale: Administering activated charcoal is the priority intervention as it binds with digoxin, preventing further absorption in the gastrointestinal tract. This helps reduce the amount of digoxin available for systemic circulation and minimizes its toxic effects. Gastric lavage is no longer recommended due to potential complications and lack of evidence of efficacy. Obtaining an electrocardiogram may help assess the effects of digoxin toxicity, but it is not the initial priority. IV digoxin immune fab (Digibind) is used in severe cases of digoxin toxicity but is not the first-line intervention.

4. The practical nurse (PN) is caring for an adolescent who has been diagnosed with mononucleosis. Which activity should the PN advise the adolescent to avoid?

• A. Playing video games.
• B. Drinking caffeinated beverages.
• C. Participating in contact sports.
• D. Eating spicy foods.

Correct answer: C

Rationale: Contact sports should be avoided in mononucleosis due to the risk of spleen rupture, which is a serious complication of the disease. The spleen can enlarge in mononucleosis, making it more susceptible to injury from contact sports, potentially leading to a life-threatening situation if rupture occurs.

5. When planning care for a child diagnosed with rheumatic fever, what is the primary goal of nursing care?

• A. Reduce fever.
• B. Maintain fluid and electrolyte balance.
• C. Prevent cardiac damage.
• D. Maintain joint mobility and function.

Correct answer: C

Rationale: The primary goal of nursing care for a child diagnosed with rheumatic fever is to prevent cardiac damage. Rheumatic fever can lead to complications affecting the heart, making it crucial to monitor and prevent cardiac involvement to avoid long-term consequences. While addressing fever and joint pain are important aspects of care, preventing cardiac damage takes precedence in managing rheumatic fever. Therefore, choices A, B, and D are not the primary goals of nursing care in this case.

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