Nursing Elites

1. The nurse is taking vital signs on a group of assigned preschool-aged children. Which assessment finding would indicate the need for further action?

• A. Respiratory rate of 20 breaths per minute
• B. Heart rate of 89 beats per minute
• C. Heart rate of 120 beats per minute
• D. Respiratory rate of 24 breaths per minute

Correct answer: C

Rationale: A heart rate of 120 beats per minute is high for a preschool-aged child and may indicate an underlying issue that requires further assessment. A respiratory rate of 20 breaths per minute (choice A) is within the normal range for preschool children. Similarly, a heart rate of 89 beats per minute (choice B) falls within the expected range. A respiratory rate of 24 breaths per minute (choice D) is slightly elevated but may not be as concerning as a heart rate of 120 beats per minute.

2. The nurse has just started assessing a young child who is febrile and appears ill. There is hyperextension of the child's head (opisthotonos) with pain on flexion. Which is the most appropriate action?

• A. Ask the parent when the neck was injured
• B. Refer for immediate medical evaluation
• C. Continue assessment to determine the cause of the neck pain
• D. Record head lag on the assessment record and continue the assessment of the child

Correct answer: B

Rationale: Opisthotonos with pain on flexion is a sign of possible meningitis or other serious neurological conditions, requiring immediate medical evaluation.

3. Which physiological acid-base balance complication would be most important for the nurse to assess in a patient with diarrhea?

• A. High serum pH
• B. Normal serum pH
• C. Metabolic alkalosis
• D. Metabolic acidosis

Correct answer: D

Rationale: The correct answer is metabolic acidosis. Diarrhea can lead to the loss of bicarbonate, causing an imbalance in the acid-base status of the body, specifically resulting in metabolic acidosis. High serum pH (choice A) is incorrect as diarrhea-induced bicarbonate loss would lower pH, not increase it. Normal serum pH (choice B) is not the best answer as diarrhea can disrupt the acid-base balance. Metabolic alkalosis (choice C) is an alkaline state, which is less likely to be caused by diarrhea.

4. 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.

5. What is the priority nursing intervention for a child with epiglottitis?

• A. Administer antibiotics
• B. Maintain airway patency
• C. Provide hydration
• D. Monitor vital signs

Correct answer: B

Rationale: The correct answer is B: Maintain airway patency. When dealing with a child with epiglottitis, the priority nursing intervention is to ensure airway patency to prevent airway obstruction, which can lead to respiratory distress or failure. Administering antibiotics (choice A) is important to treat the infection, but airway management takes precedence. Providing hydration (choice C) and monitoring vital signs (choice D) are essential aspects of care but are secondary to securing the airway in a child with epiglottitis.

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