Nursing Elites

1. How should the nurse prepare the sibling of a near-drowning accident victim who wants to see his brother in the pediatric intensive care unit, considering the child was present during the accident?

• A. Have the parents explain to the child why the sibling is so sick and inform the child that this could be the last time he sees his brother.
• B. Reassure the sibling not to cry in the child's room to avoid upsetting the ill child.
• C. If death is imminent, avoid informing the child about it and minimize involvement in care to protect the child from further trauma.
• D. Cover tubes and wires with a sheet, wash off any existing blood, and prepare him for what he will see.

Correct answer: D

Rationale: When preparing a sibling to see their brother in the pediatric intensive care unit after a near-drowning accident, it is essential to cover tubes and wires with a sheet, wash off any existing blood, and explain what the sibling will see. This approach helps the sibling understand the situation better and prepares them emotionally for the encounter, reducing potential distress and trauma. By providing information and visual preparation, the sibling can have a more controlled and less overwhelming experience when visiting their brother in the intensive care unit. Choice A is incorrect as informing the child that this could be the last time he sees his sibling may cause unnecessary distress and anxiety. Choice B is incorrect as it dismisses the sibling's emotional response, which is essential to address in a supportive manner. Choice C is incorrect as honesty and appropriate information sharing are crucial, even in difficult situations, to help the child cope effectively with the circumstances.

2. A new mother asks the nurse when she should begin to breastfeed her newborn. The nurse's best response is:

• A. Within the first half-hour after birth
• B. After the newborn's first bath
• C. When the newborn begins to cry
• D. After administering vitamin K

Correct answer: A

Rationale: Initiating breastfeeding within the first half-hour after birth is crucial for successful breastfeeding and bonding, as recommended by the World Health Organization. This early initiation helps establish breastfeeding and supports the newborn's health by providing colostrum, the nutrient-rich first milk. Choice B, 'After the newborn's first bath,' is incorrect because initiating breastfeeding should not be delayed after birth. Choice C, 'When the newborn begins to cry,' is incorrect as it does not promote timely initiation of breastfeeding. Choice D, 'After administering vitamin K,' is incorrect because breastfeeding initiation should not be delayed for this procedure.

3. Your assessment of a newborn reveals cyanosis to the chest and face and a heart rate of 90 beats/min. What should you do first?

• A. Dry the infant briskly.
• B. Suction the mouth.
• C. Begin artificial ventilations.
• D. Begin chest compressions.

Correct answer: C

Rationale: In a newborn with cyanosis to the chest and face and a heart rate of 90 beats/min, the priority action is to begin artificial ventilations. A heart rate below 100 beats/min with cyanosis indicates a need for immediate respiratory support to improve oxygenation. Drying the infant briskly or suctioning the mouth may be necessary later but are not the initial priority. Chest compressions are not indicated as the heart rate is above 60 beats/min.

4. Which statement best describes direct contact as a mode of pathogen transmission?

• A. Transmission through large aerosols produced by sneezing or coughing
• B. Transfer of an infectious agent by suspended air particles from a reservoir to a host
• C. Transmission of infectious agents carried by dust
• D. Transmission through skin-to-skin contact or body fluids

Correct answer: D

Rationale: Direct contact transmission occurs when pathogens are spread through skin-to-skin contact or body fluids. This mode of transmission includes activities like touching, kissing, or sexual contact where infectious agents can pass directly from one person to another. It does not involve large aerosols, suspended air particles, or dust as carriers of the pathogen.

5. An 18-month-old child presents with fever, nasal flaring, intercostal retractions, and a respiratory rate of 50 bpm. What is the most appropriate nursing diagnosis?

• A. High risk for altered body temperature - hyperthermia
• B. Ineffective breathing pattern
• C. Ineffective individual coping
• D. Knowledge deficit

Correct answer: B

Rationale: In this case, the child is showing signs of respiratory distress, such as nasal flaring, intercostal retractions, and an increased respiratory rate. These are indicative of an ineffective breathing pattern. The child's compromised respiratory function requires immediate attention and intervention, making 'Ineffective breathing pattern' the most appropriate nursing diagnosis. Choices A, C, and D do not address the respiratory distress the child is experiencing and are not the priority in this situation.

Similar Questions