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. What intervention is crucial during a sickle cell crisis in a child?

• A. Administer oxygen
• B. Apply cold compresses
• C. Restrict fluids
• D. Encourage bed rest

Correct answer: A

Rationale: Administering oxygen is crucial during a sickle cell crisis in a child as it helps to prevent further sickling of cells. Oxygen therapy can improve oxygen saturation levels, reducing the risk of tissue damage and complications. Applying cold compresses (choice B) is not recommended as it can potentially worsen vaso-occlusive crisis by causing vasoconstriction. Restricting fluids (choice C) is not appropriate as hydration is essential to prevent dehydration and maintain adequate blood flow. Encouraging bed rest (choice D) may be necessary but administering oxygen takes precedence in managing a sickle cell crisis.

3. The charge nurse in the pediatric unit is teaching nursing students about pyloric stenosis. A student asks what causes pyloric stenosis. How should the nurse respond?

• A. One portion of the intestines invaginates or telescopes into another
• B. Hypertrophy of the circular pylorus muscle
• C. Relaxed cardiac sphincter
• D. Absent ganglion cells in the colon

Correct answer: B

Rationale: Pyloric stenosis is caused by the hypertrophy (thickening) of the circular muscle of the pylorus, leading to obstruction. Choice A is incorrect as it describes intussusception, not pyloric stenosis. Choice C is incorrect as a relaxed cardiac sphincter is related to gastroesophageal reflux. Choice D is incorrect as it describes Hirschsprung's disease, not pyloric stenosis.

4. The nurse is teaching a child experiencing severe edema associated with minimal change nephrotic syndrome about his diet. The nurse should discuss what dietary need?

• A. Consuming a regular diet
• B. Increasing protein
• C. Restricting fluids
• D. Decreasing calories

Correct answer: C

Rationale: Fluid restriction is often necessary to manage severe edema associated with MCNS. Increasing protein is not typically recommended due to the risk of exacerbating proteinuria, and calorie reduction is not generally needed.

5. The parents of a 2-month-old boy are concerned about spoiling their son by picking him up when he cries. What is the nurse's best response?

• A. Allow him to cry for no longer than 15 minutes and then pick him up
• B. Babies need comforting and cuddling. Meeting these needs will not spoil him
• C. Babies this young cry when they are hungry. Try feeding him when he cries
• D. If he isn’t soiled or wet, leave him, and he'll cry himself to sleep

Correct answer: B

Rationale: Comforting and cuddling a 2-month-old baby when they cry helps build trust and security. At this age, responding to cries does not lead to spoiling, but rather supports healthy emotional development.

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