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 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.

3. An infant requires surgery for repair of a cleft lip. An important priority of the preoperative nursing care is which?

• A. Initiating discharge teaching
• B. Performing baseline physical and behavioral assessment
• C. Observing for allergic reactions to preoperative antibiotics
• D. Determining whether this defect exists in other family members

Correct answer: B

Rationale: Performing a baseline physical and behavioral assessment is crucial to determine the infant's current health status and to identify any potential risks before surgery.

4. A 7-year-old has been diagnosed with cystic fibrosis. Chest physiotherapy has been ordered. What information should the nurse give to the parents regarding when chest physiotherapy is done?

• A. Before aerosol treatment
• B. After suctioning
• C. Before postural drainage
• D. Before meals

Correct answer: D

Rationale: The correct answer is D: 'Before meals'. Chest physiotherapy should be performed before meals to reduce the risk of vomiting and to ensure that the airways are clear for effective nutrition. Choices A, B, and C are incorrect because chest physiotherapy is ideally done before meals to optimize its benefits and avoid complications associated with timing.

5. The nurse is teaching a nursing student about standard precautions. Which statement made by the student indicates a need for further teaching?

• A. I will use precautions when I give an infant oral care
• B. I will use precautions when I change an infant's diaper
• C. I will use precautions when I come in contact with blood and body fluids
• D. I will use precautions when administering oral medications to a school-age child

Correct answer: D

Rationale: Standard precautions are necessary when dealing with blood, body fluids, and potentially infectious materials. They are not required for routine administration of oral medications unless there is a potential exposure risk.

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