Nursing Elites

1. The healthcare provider is caring for a 3-year-old child who is hospitalized with dehydration. The child is now receiving IV fluids and has started to produce urine. What is the best indicator that the child’s dehydration is improving?

• A. The child’s urine output has increased
• B. The child’s skin turgor is normal
• C. The child’s weight has increased
• D. The child’s vital signs are stable

Correct answer: A

Rationale: An increase in urine output is a reliable indicator that the child's hydration status is improving. Adequate urine output signifies that the kidneys are functioning properly and that the body is effectively eliminating waste and excess fluids, indicating improved hydration levels. The other options are not as direct indicators of hydration status. Skin turgor and weight changes can be influenced by various factors, and stable vital signs do not specifically reflect hydration status.

2. The healthcare provider is evaluating the effects of thyroid therapy used to treat a 5-month-old with hypothyroidism. Which behavior indicates that the treatment has been effective?

• A. Laughs readily, turns from back to side.
• B. Has strong Moro and tonic neck reflexes.
• C. Keeps fists clenched, opens hands when grasping an object.
• D. Can lift head, but not chest when lying on abdomen.

Correct answer: A

Rationale: In infants, laughing readily and turning from back to side are indicative of normal development. These behaviors indicate that the thyroid therapy is effective, as they suggest the baby is achieving age-appropriate milestones. A 5-month-old infant should be able to laugh readily and turn from back to side, showing progress in motor and social development. Choices B, C, and D describe behaviors that are not specific to the expected developmental milestones of a 5-month-old. Strong Moro and tonic neck reflexes, clenched fists, and limited ability to lift the chest when lying on the abdomen are not necessarily indicative of the effectiveness of thyroid therapy for hypothyroidism.

3. During a follow-up clinical visit, a mother tells the nurse that her 5-month-old son, who had surgical correction for tetralogy of Fallot, has rapid breathing, often takes a long time to eat, and requires frequent rest periods. The infant is not crying while being held, and his growth is in the expected range. Which intervention should the nurse implement?

• A. Stimulate the infant to cry to produce cyanosis
• B. Auscultate the heart and lungs while holding the infant
• C. Evaluate the infant for failure to thrive
• D. Obtain a 12-lead electrocardiogram

Correct answer: B

Rationale: Auscultating the heart and lungs while the infant is held is the most appropriate intervention to assess his current condition. This action allows the nurse to gather important information regarding the cardiovascular and respiratory status of the infant, which is crucial in evaluating his post-surgical recovery and overall well-being. Option A is incorrect as stimulating the infant to cry intentionally is not necessary and could cause distress. Option C is incorrect as the infant's growth is within the expected range, indicating no signs of failure to thrive. Option D is incorrect as obtaining a 12-lead electrocardiogram is not the initial intervention needed in this situation; assessing the heart and lungs through auscultation is more immediate and informative.

4. 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.

5. The nurse is caring for a 2-year-old child who was admitted for dehydration due to gastroenteritis. The child is now receiving IV fluids and appears more alert. What is the best indicator that the child’s condition is improving?

• A. The child is more alert and playful
• B. The child’s urine output has increased
• C. The child’s vital signs are stable
• D. The child is tolerating small amounts of oral fluids

Correct answer: B

Rationale: Increased urine output is a reliable indicator that hydration status is improving. While alertness and playfulness are positive signs, increased urine output directly reflects improved hydration. Stable vital signs are important but may not directly indicate hydration status. Tolerating small amounts of oral fluids is a good sign but may not be as direct an indicator as increased urine output.

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