Nursing Elites

1. The practical nurse is caring for a child who has just returned from surgery for an appendectomy. Which intervention should the nurse implement?

• A. Encourage early ambulation.
• B. Apply warm compresses to the incision site.
• C. Monitor for signs of infection at the surgical site.
• D. Provide a high-fiber diet immediately post-op.

Correct answer: C

Rationale: Monitoring for signs of infection at the surgical site is crucial after an appendectomy as it helps in early detection and treatment of any potential complications. This intervention is essential for ensuring the child's proper healing and recovery post-surgery. Encouraging early ambulation is generally beneficial post-operatively but may not be the priority immediately after an appendectomy. Applying warm compresses to the incision site may not be indicated as it can increase the risk of infection. Providing a high-fiber diet immediately post-op is not recommended as the digestive system needs time to recover from surgery.

2. The practical nurse is caring for a child who was admitted for treatment of seizures. Which intervention should the nurse implement to help prevent injury from a seizure?

• A. Have a padded tongue depressor at the bedside.
• B. Keep the side rails padded and in an upright position.
• C. Place a padded helmet on the child’s head.
• D. Restrain the child during the seizure activity.

Correct answer: B

Rationale: The correct intervention to help prevent injury during a seizure is to keep the side rails padded and in an upright position. This measure helps to ensure the child's safety by preventing falls or accidental injuries. Using a padded tongue depressor or restraining the child can potentially cause harm and are not recommended. Placing a padded helmet is not a standard intervention for seizure safety in this scenario.

3. What action should the nurse implement when the infusion of chemotherapy via an implanted medication port is complete for a 16-year-old with acute myelocytic leukemia at the outpatient oncology clinic?

• A. Administer Zofran
• B. Obtain blood samples for RBCs, WBCs, and platelets
• C. Flush mediport with saline and heparin solution
• D. Initiate an infusion of normal saline

Correct answer: C

Rationale: The correct action for the nurse to implement when the chemotherapy infusion is complete is to flush the mediport with saline and heparin solution. This process helps prevent clotting and ensures the patency of the port, which is essential for future medication administrations and blood draws. Administering Zofran (Choice A) is not necessary after completing the chemotherapy infusion. Obtaining blood samples (Choice B) for RBCs, WBCs, and platelets is important but not the immediate action after completing the infusion. Initiating an infusion of normal saline (Choice D) is not required unless there is a specific indication for it.

4. The nurse is measuring the frontal occipital circumference (FOC) of a 3-month-old infant and notes that the FOC has increased by 5 inches since birth, and the child's head appears large in relation to body size. Which action is most important for the nurse to take next?

• A. Measure the infant's head-to-toe length.
• B. Palpate the anterior fontanel for tension and bulging.
• C. Observe the infant for sunken eyes.
• D. Plot the measurement on the infant's growth chart.

Correct answer: B

Rationale: Palpating the anterior fontanel for tension and bulging is crucial in assessing for increased intracranial pressure. In this scenario, the infant's large head size and rapid increase in the frontal occipital circumference raise concerns for potential issues such as hydrocephalus. Measuring the head-to-toe length (Choice A) is not the priority when assessing for increased intracranial pressure. Observing for sunken eyes (Choice C) is more indicative of dehydration rather than increased intracranial pressure. While plotting the measurement on the infant's growth chart (Choice D) is important for tracking growth, it does not address the immediate concern of assessing for increased intracranial pressure.

5. During a follow-up clinical visit, a mother tells the nurse that her 5-month-old son, who had surgical correction for tetralogy of Fallot, has rapid breathing, often takes a long time to eat, and requires frequent rest periods. The infant is not crying while being held, and his growth is in the expected range. Which intervention should the nurse implement?

• A. Stimulate the infant to cry to produce cyanosis
• B. Auscultate the heart and lungs while holding the infant
• C. Evaluate the infant for failure to thrive
• D. Obtain a 12-lead electrocardiogram

Correct answer: B

Rationale: Auscultating the heart and lungs while the infant is held is the most appropriate intervention to assess his current condition. This action allows the nurse to gather important information regarding the cardiovascular and respiratory status of the infant, which is crucial in evaluating his post-surgical recovery and overall well-being. Option A is incorrect as stimulating the infant to cry intentionally is not necessary and could cause distress. Option C is incorrect as the infant's growth is within the expected range, indicating no signs of failure to thrive. Option D is incorrect as obtaining a 12-lead electrocardiogram is not the initial intervention needed in this situation; assessing the heart and lungs through auscultation is more immediate and informative.

Similar Questions