Nursing Elites

1. What is an essential nursing action when caring for a young child with severe diarrhea?

• A. Maintain the IV.
• B. Take daily weights.
• C. Replace the lost calories.
• D. Promote perianal skin integrity.

Correct answer: D

Rationale: Promoting perianal skin integrity is crucial when caring for a young child with severe diarrhea as it helps prevent skin breakdown from the irritation caused by frequent stooling. Maintaining the IV (Choice A) may be necessary but is not directly related to managing perianal skin integrity. Taking daily weights (Choice B) is important for monitoring fluid status but not the priority when addressing perianal skin integrity. While replacing lost calories (Choice C) is essential, promoting perianal skin integrity takes precedence in preventing complications associated with skin breakdown.

2. A 5-year-old child with a diagnosis of asthma is being evaluated for medication management. What is an important assessment for the nurse to perform?

• A. Assess the child's sleep patterns
• B. Assess the child's dietary intake
• C. Assess the child's academic performance
• D. Assess the child's behavior at home

Correct answer: B

Rationale: Assessing the child's dietary intake is crucial in managing asthma as certain foods can trigger symptoms or exacerbate the condition. Monitoring the child's diet can help identify triggers, ensure proper nutrition, and support the child's overall health. Assessing sleep patterns (Choice A) may be relevant but is not as directly linked to asthma management as dietary intake. Academic performance (Choice C) and behavior at home (Choice D) are important aspects of a child's well-being but are not directly related to asthma management.

3. Based on developmental norms for a 5-year-old child, a healthcare professional decides to withhold a scheduled dose of digoxin (Lanoxin) elixir and notify the healthcare provider. Below what apical pulse did the healthcare professional withhold the medication?

• A. 60 beats/min
• B. 70 beats/min
• C. 90 beats/min
• D. 100 beats/min

Correct answer: C

Rationale: For a 5-year-old child, an apical pulse below 90 beats/min is an indicator to withhold digoxin. Digoxin is a medication that affects the heart, and in pediatric patients, monitoring the pulse rate is crucial due to the risk of bradycardia (slow heart rate) as a potential side effect. In this case, an apical pulse of 90 beats/min or lower indicates a heart rate that may be too slow for a child of this age, warranting the withholding of digoxin and prompt notification of the healthcare provider. Choices A, B, and D are not within the critical range specified for withholding digoxin in a 5-year-old child and would not necessitate withholding the medication.

4. When administering IV fluids to a dehydrated infant, what intervention is most important at this time?

• A. Continuing the prescribed flow rate
• B. Monitoring the intravenous drop rate
• C. Calculating the total necessary intake
• D. Maintaining the fluid at body temperature

Correct answer: B

Rationale: Monitoring the intravenous drop rate is crucial when administering IV fluids to ensure that the correct amount of fluids is delivered to the dehydrated infant. Choice A assumes the initial rate is correct without ongoing assessment. Choice C, while important, does not address the immediate need for monitoring the infusion rate. Choice D, maintaining the fluid at body temperature, is essential for comfort but is not as critical as ensuring the correct fluid delivery rate. By monitoring the intravenous drop rate, healthcare providers can adjust the flow as needed to prevent overhydration or underhydration, helping to manage the infant's fluid balance effectively.

5. A child has been diagnosed with gastroesophageal reflux disease (GERD). What position should the nurse recommend the child be placed in after eating?

• A. Supine
• B. Prone
• C. Semi-Fowler's
• D. Trendelenburg

Correct answer: C

Rationale: After eating, it is beneficial to place a child with GERD in a semi-Fowler's position. This position helps prevent reflux by keeping the child's head elevated above the stomach, reducing the chances of gastric contents flowing back into the esophagus. Placing the child supine (lying flat on their back) can worsen reflux symptoms by allowing gravity to work against the natural flow of gastric contents. Prone position (lying on the stomach) is not recommended due to the increased risk of aspiration. Trendelenburg position (feet elevated above head) is also inappropriate as it can lead to increased pressure on the abdomen, potentially worsening reflux symptoms.

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