Nursing Elites

1. The nurse is caring for a child who had a tonsillectomy. Which clinical manifestation should the nurse observe the child for in the postoperative period?

• A. Arrhythmias
• B. Increased swallowing
• C. Increased blood sugar
• D. Increased urinary output

Correct answer: B

Rationale: Correct Answer: B. Increased swallowing can indicate bleeding at the surgical site, which is a potential complication after tonsillectomy. Choice A, Arrhythmias, are not typically associated with tonsillectomy. Choice C, Increased blood sugar, is not a common clinical manifestation after a tonsillectomy. Choice D, Increased urinary output, is not a typical clinical manifestation to observe for in the postoperative period after a tonsillectomy.

2. Which condition is most commonly associated with a 'sunset sign' in infants?

• A. Hydrocephalus
• B. Meningitis
• C. Cerebral palsy
• D. Encephalitis

Correct answer: A

Rationale: The 'sunset sign,' characterized by downward-driven eyes, is most commonly associated with hydrocephalus. This condition causes increased intracranial pressure, leading to the eyes appearing to be forced downward. Meningitis (choice B) typically presents with symptoms such as fever, headache, and a stiff neck, but not the 'sunset sign.' Cerebral palsy (choice C) is a group of disorders affecting movement and muscle coordination, not directly related to the 'sunset sign.' Encephalitis (choice D) is inflammation of the brain, which can cause symptoms like fever, headache, and confusion, but not the specific downward eye gaze seen in the 'sunset sign.'

3. Which nursing intervention should be included in the postoperative care of a child following a tonsillectomy?

• A. Encourage the child to blow the nose gently
• B. Notify the physician if mucus is observed in the emesis
• C. Position the child supine in the immediate postoperative period
• D. Avoid giving citrus juice

Correct answer: D

Rationale: The correct answer is D: 'Avoid giving citrus juice.' Citrus juice can irritate the throat after a tonsillectomy, so it should be avoided. Choice A is incorrect because blowing the nose gently is not a recommended intervention following a tonsillectomy. Choice B is incorrect as mucus in emesis is not uncommon postoperatively and does not necessarily require physician notification. Choice C is incorrect as positioning the child supine immediately postoperatively can increase the risk of airway obstruction and should be avoided.

4. A parent and 4-year-old child are waiting in an exam room when the nurse enters and greets them. Which activity that the nurse observes the child doing would best demonstrate the primary developmental task of the preschool-age child, according to Erikson?

• A. Reading a book
• B. Singing a song he learned at preschool
• C. Opening drawers in the room, pulling out supplies, and examining them
• D. Roughhousing with the parent

Correct answer: C

Rationale: The correct answer is C. According to Erikson, the primary task of a preschool-aged child is to explore and assert control over their environment. This behavior is demonstrated by the child opening drawers, pulling out supplies, and examining them, showcasing curiosity and exploration. Choices A, B, and D do not align with the primary developmental task of a preschool-age child according to Erikson. Reading a book and singing a song are more passive activities, while roughhousing with the parent does not directly relate to exploration and asserting control over the environment.

5. The nurse is caring for an infant who had surgical repair of a tracheoesophageal fistula 24 hours ago. Gastrostomy feedings have not been started. What do nursing actions related to the gastrostomy tube include?

• A. Keep the tube clamped.
• B. Suction the tube as needed.
• C. Leave the tube open to gravity drainage.
• D. Secure the tube with tape.

Correct answer: C

Rationale: Leaving the gastrostomy tube open to gravity drainage prevents the accumulation of air and fluids, reducing the risk of complications such as vomiting or aspiration in the immediate postoperative period. Keeping the tube clamped or suctioning it can lead to pressure buildup, increasing the risk of complications. Securing the tube with tape is important but not the primary action related to the gastrostomy tube in this case.

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