Nursing Elites

1. What is important to include in discharge instructions for parents of a child who has had a tonsillectomy?

• A. Encourage the child to gargle with salt water
• B. Encourage fluid intake
• C. Provide the child with hard candy
• D. Apply heat to the neck

Correct answer: B

Rationale: Encouraging fluid intake is essential in the discharge instructions for a child who has had a tonsillectomy. It helps keep the throat moist, aids in preventing dehydration, and promotes healing. Gargling with salt water is not typically recommended after a tonsillectomy as it may irritate the surgical site. Providing the child with hard candy is not advisable as it can irritate the throat and potentially cause harm. Applying heat to the neck is also not recommended post-tonsillectomy as it can increase swelling and discomfort in the surgical area.

2. A 4-year-old child is scheduled for a myringotomy. What should the nurse include in the preoperative teaching?

• A. Explain the procedure in simple terms
• B. Encourage fluid intake
• C. Allow the child to play with medical equipment
• D. Use play therapy to prepare the child

Correct answer: A

Rationale: Explaining the procedure in simple terms is essential preoperative teaching for a 4-year-old child scheduled for a myringotomy. This approach helps the child understand what will happen during the procedure, reducing anxiety and fear. Encouraging fluid intake is a good general health practice but not directly related to preoperative teaching for this procedure. Allowing the child to play with medical equipment may not be safe or appropriate as it can lead to misunderstanding or fear. Using play therapy can be beneficial but explaining the procedure in simple terms is more direct and effective for preoperative teaching in this case.

3. A nurse is evaluating a 3-year-old child’s developmental progress. The inability to perform which task indicates to the nurse that there is a developmental delay?

• A. Copying a square
• B. Hopping on one foot
• C. Catching a ball reliably
• D. Using a spoon effectively

Correct answer: A

Rationale: The inability to copy a square at 3 years old indicates a potential developmental delay in fine motor skills. At this age, children should be able to copy basic shapes like circles and crosses. Hopping on one foot is typically expected around the age of 4, catching a ball reliably around 5, and using a spoon effectively by 2-3 years old. Therefore, choices B, C, and D are not as indicative of a developmental delay at 3 years old as the inability to copy a square.

4. Which of the following signs or symptoms is more common in children than adults following head trauma?

• A. nausea and vomiting
• B. altered mental status
• C. tachycardia and diaphoresis
• D. changes in pupillary reaction

Correct answer: A

Rationale: Nausea and vomiting are more common in children following head trauma due to their higher risk of increased intracranial pressure. Children have less skull compliance and higher brain water content, making them more susceptible to developing symptoms like nausea and vomiting. Altered mental status (choice B) can occur in both children and adults but is not more common in children. Tachycardia and diaphoresis (choice C) are nonspecific and can occur in both age groups. Changes in pupillary reaction (choice D) are not typically more common in children following head trauma compared to adults.

5. The parents of a child who is scheduled for open-heart surgery ask why their child must be subjected to chest tubes after surgery. What should the nurse consider before responding in language the parents will understand?

• A. They will increase tidal volumes.
• B. Drainage of air and fluid will be facilitated.
• C. They will maintain positive intrapleural pressure.
• D. Pressure on the pericardium and chest wall will be regulated.

Correct answer: B

Rationale: Chest tubes are necessary after open-heart surgery to facilitate the drainage of air and fluid from the chest cavity. These tubes help prevent complications such as pneumothorax (accumulation of air in the pleural space) or cardiac tamponade (build-up of fluid in the pericardial sac), which can be serious postoperative issues. Options A, C, and D are incorrect because chest tubes are primarily used for draining purposes and not for increasing tidal volumes, maintaining positive intrapleural pressure, or regulating pressure on the pericardium and chest wall.

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