Nursing Elites

1. What clinical manifestation(s) should the nurse expect to see as shock progresses in a child and becomes decompensated shock?

• A. Thirst
• B. Irritability
• C. Apprehension
• D. Confusion and somnolence

Correct answer: D

Rationale: As shock progresses and decompensation occurs, confusion and somnolence are indicative of reduced cerebral perfusion. Early signs include thirst and irritability, while confusion and altered consciousness appear as the condition worsens.

2. When should the dressing change for a post-op pediatric patient that is expected to be very painful and frightening be performed?

• A. In the patient’s room
• B. In the treatment room
• C. After discharge when the patient is at home
• D. In the playroom

Correct answer: B

Rationale: The correct answer is B: 'In the treatment room.' Performing painful procedures in the treatment room helps the child associate their own room with safety and comfort, not pain. Choice A is incorrect because performing the dressing change in the patient’s room may create a negative association with their safe space. Choice C is incorrect as it is important to ensure proper wound care and pain management before discharge. Choice D is incorrect as the playroom may not be equipped for a sterile dressing change.

3. What tool would be most useful to assess maternal and newborn attachment behaviors?

• A. Apgar
• B. Ballard scale
• C. NCAST (Nursing Child Assessment Satellite Training) Feeding Scale
• D. Brazelton Neonatal Behavioral Assessment Scale

Correct answer: C

Rationale: The NCAST Feeding Scale is the most suitable tool to evaluate maternal and newborn attachment behaviors during feedings. It focuses on observing the interaction between the parent and infant, providing insights into their bonding. The Apgar score is used to assess a neonate's immediate transition to life outside the womb, not specifically maternal and newborn attachment behaviors. The Ballard scale is used to estimate gestational age, not to assess attachment behaviors. The Brazelton Neonatal Behavioral Assessment Scale is designed to evaluate a newborn's responses to various stimuli, not specifically maternal and newborn attachment behaviors.

4. A child has a central venous access device for intravenous (IV) fluid administration. A blood sample is needed for a complete blood count, hemogram, and electrolytes. What is the appropriate procedure to implement for this blood sample?

• A. Perform a new venipuncture to obtain the blood sample.
• B. Interrupt the IV fluid and withdraw the blood sample needed.
• C. Withdraw a blood sample equal to the amount of fluid in the device, discard, and then withdraw the sample needed.
• D. Flush the line and central venous device with saline and then aspirate the required amount of blood for the sample.

Correct answer: C

Rationale: Withdrawing and discarding a sample equal to the amount of fluid in the device ensures that the blood drawn is not diluted by the IV fluids, providing accurate lab results.

5. Which is a complication that can occur after abdominal surgery if pain is not managed?

• A. Atelectasis
• B. Hypoglycemia
• C. Decrease in heart rate
• D. Increase in cardiac output

Correct answer: A

Rationale: Poorly managed pain after abdominal surgery can lead to complications like atelectasis due to shallow breathing, which may occur if the child avoids deep breaths because of pain.

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