Nursing Elites

1. The parents of a child born with ambiguous genitalia tell the nurse that family and friends are asking what caused the baby to be this way. Tests are being done to assist in gender assignment. What should the nurse's intervention include?

• A. Explain the disorder so they can explain it to others.
• B. Help parents understand that this is a minor problem.
• C. Suggest that parents avoid family and friends until the gender is assigned.
• D. Encourage parents not to worry while the tests are being done.

Correct answer: A

Rationale: It is important for the nurse to provide the parents with accurate information so they can confidently explain the situation to others, helping to reduce stress and misinformation. Avoiding family and friends or minimizing the problem is not helpful.

2. When auscultating an infant's lungs, the nurse detects diminished breath sounds. What should the nurse interpret this as?

• A. Suggestive of chronic pulmonary disease
• B. Suggestive of impending respiratory failure
• C. An abnormal finding warranting investigation
• D. A normal finding in infants younger than 1 year of age

Correct answer: C

Rationale: Diminished breath sounds in an infant are an abnormal finding and warrant further investigation to rule out conditions like atelectasis or pneumonia.

3. A 5-year-old has patient-controlled analgesia (PCA) for pain management after abdominal surgery. What information does the nurse include in teaching the parents about the PCA?

• A. The child may not be pain-free.
• B. The parents or nurse may push the button for a bolus if needed.
• C. The pump allows for a continuous basal rate to deliver a constant amount of medication for pain control.
• D. Monitoring is required every 1 to 2 hours to assess patient response.

Correct answer: C

Rationale: The correct answer is C because the PCA pump can be programmed to deliver a continuous basal rate of pain medication to maintain pain control. While the goal of PCA is effective pain relief, it does not guarantee a pain-free state. In the case of a 5-year-old child, the parents or nurse can administer boluses if necessary since the child may not fully comprehend using the PCA button. Monitoring every 1 to 2 hours for patient response is adequate and there is no need for monitoring every 15 minutes, as stated in choice D, unless specific circumstances dictate more frequent monitoring.

4. What is an appropriate nursing intervention for a child with minimal change nephrotic syndrome (MCNS) who has scrotal edema?

• A. Place an ice pack on the scrotal area.
• B. Place the child in an upright sitting position.
• C. Elevate the scrotum with a rolled washcloth.
• D. Place a warm moist pack to the scrotal area.

Correct answer: C

Rationale: Elevating the scrotum with a rolled washcloth helps reduce edema by promoting fluid drainage. Ice packs are not recommended due to the risk of frostbite, and warm moist packs are not typically used for this purpose. An upright position does not specifically address the edema.

5. A child with pyloric stenosis is having excessive vomiting. The nurse should assess for what potential complication?

• A. Hyperkalemia
• B. Hyperchloremia
• C. Metabolic acidosis
• D. Metabolic alkalosis

Correct answer: D

Rationale: Excessive vomiting in pyloric stenosis leads to the loss of stomach acid (hydrochloric acid), resulting in metabolic alkalosis, not hyperkalemia, hyperchloremia, or metabolic acidosis. Metabolic alkalosis is characterized by a higher pH level in the blood due to the loss of acid and a relative increase in bicarbonate. Hyperkalemia is an elevated level of potassium in the blood and is not directly related to excessive vomiting in pyloric stenosis. Hyperchloremia is an excess of chloride in the blood, which is not typically associated with this condition. Metabolic acidosis is a condition characterized by a lower pH level in the blood, caused by an excess of acid or a loss of bicarbonate, which is not the typical complication seen in pyloric stenosis with excessive vomiting.

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