Nursing Elites

1. What is an important nursing responsibility when a dysrhythmia is suspected?

• A. order an immediate electrocardiogram
• B. count the radial pulse every 1 minute for five times
• C. count the apical pulse for 1 full minute, and compare the rate with the radial pulse rate
• D. have someone else take the radial pulse simultaneously with the apical pulse

Correct answer: C

Rationale: When a dysrhythmia is suspected, an important nursing responsibility is to count the apical pulse for 1 full minute and then compare this rate with the radial pulse rate. This method helps in identifying dysrhythmias as it allows for a direct comparison of the heart's rhythm at two different pulse points. Ordering an immediate electrocardiogram (Choice A) may be necessary but should not be the first step. Counting the radial pulse multiple times (Choice B) is not as accurate as comparing rates directly. Having someone else take the radial pulse simultaneously (Choice D) may introduce errors and inconsistencies in the measurement.

2. A child with a diagnosis of pyloric stenosis is scheduled for surgery. What preoperative intervention is important for the nurse to perform?

• A. Administering intravenous fluids
• B. Monitoring for signs of infection
• C. Monitoring for signs of dehydration
• D. Monitoring for signs of pain

Correct answer: C

Rationale: The correct preoperative intervention for a child with pyloric stenosis is to monitor for signs of dehydration. Pyloric stenosis can lead to vomiting, which can result in dehydration. Monitoring for signs of dehydration is crucial to ensure the child's fluid balance is maintained. Administering intravenous fluids, although important for managing dehydration and electrolyte imbalances, would typically be done postoperatively rather than as a preoperative intervention. Monitoring for signs of infection is important but not specific to the preoperative period for pyloric stenosis. Monitoring for signs of pain is also important but may not be the most critical preoperative intervention in this scenario.

3. A healthcare provider is assessing a child with suspected bacterial meningitis. What clinical manifestation is the healthcare provider likely to observe?

• A. Photophobia
• B. High fever
• C. Rash
• D. Nasal congestion

Correct answer: B

Rationale: High fever is a key clinical manifestation of bacterial meningitis due to the inflammatory response in the meninges. Photophobia, choice A, is also commonly observed due to meningeal irritation, but it is not as specific as high fever. Rash, choice C, is more indicative of conditions like meningococcal meningitis rather than bacterial meningitis. Nasal congestion, choice D, is not typically associated with bacterial meningitis. Therefore, the correct answer is B.

4. When obtaining a health history from parents of a 4-month-old boy with congenital hypothyroidism, what would the nurse most likely assess?

• A. The child's growth is above normal for his age.
• B. The child is active and playful.
• C. The skin appears pink and healthy.
• D. It is difficult to keep the child awake.

Correct answer: D

Rationale: In congenital hypothyroidism, infants often experience lethargy and difficulty staying awake due to low thyroid hormone levels. Choice A is incorrect as hypothyroidism can lead to poor growth in infants. Choice B is incorrect because hypothyroidism can cause decreased activity levels and lethargy rather than being active and playful. Choice C is incorrect as hypothyroidism can result in dry skin and poor skin tone, not necessarily pink and healthy-looking skin.

5. When caring for an alert 4-year-old child with a mild airway obstruction, respiratory distress, a strong cough, and normal skin color, what should be included?

• A. Back blows, abdominal thrusts, transport
• B. Oxygen, avoiding agitation, transport
• C. Assisting ventilations, back blows, transport
• D. Chest thrusts, finger sweeps, transport

Correct answer: B

Rationale: The correct approach for a child with a mild airway obstruction, respiratory distress, and normal skin color includes providing oxygen to support breathing, avoiding agitation that could worsen the situation, and arranging for transport to a healthcare facility. Option A is incorrect because abdominal thrusts are not recommended in a mild airway obstruction scenario, and back blows are typically used for choking. Option C is incorrect because assisting ventilations may not be necessary in a child with a strong cough and normal skin color. Option D is incorrect because chest thrusts are not recommended for a mild airway obstruction, and finger sweeps are used for foreign body airway obstructions.

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