Nursing Elites

1. When assessing a 5-year-old boy with major trauma, his blood pressure is 70/40 mm Hg, and his pulse rate is 140 beats/min and weak. The child's blood pressure:

• A. indicates decompensated shock.
• B. reflects adequate compensation.
• C. suggests increased intracranial pressure.
• D. is appropriate based on his age.

Correct answer: A

Rationale: In a 5-year-old boy with major trauma, a blood pressure of 70/40 mm Hg and a pulse rate of 140 beats/min, and weak, indicate decompensated shock. This presentation signifies inadequate perfusion, leading to compensatory mechanisms being overwhelmed, resulting in decompensated shock. Choice B is incorrect as the vital signs suggest the body is unable to adequately compensate for the trauma. Choice C is incorrect as the vital signs are more indicative of shock rather than increased intracranial pressure. Choice D is incorrect as such low blood pressure is not appropriate for a child of this age and indicates a critical condition.

2. 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: The most appropriate nursing diagnosis for the 18-month-old child presenting with fever, nasal flaring, intercostal retractions, and a respiratory rate of 50 bpm is 'Ineffective breathing pattern.' These symptoms collectively indicate respiratory distress, which aligns with the nursing diagnosis of ineffective breathing pattern. Nasal flaring, intercostal retractions, and an increased respiratory rate are signs of respiratory distress in pediatric patients, suggesting the need for immediate intervention to address the underlying breathing difficulties.

3. The nurse is planning the care of a hospitalized 4-year-old. The most appropriate technique the nurse can use to reduce the stress of hospitalization for this child is to:

• A. Encourage the child to discuss their feelings.
• B. Encourage peer visitation.
• C. Encourage the child to play with safe medical equipment.
• D. Read a story to the child.

Correct answer: C

Rationale: Encouraging the child to play with safe medical equipment is the most appropriate technique to reduce stress for a hospitalized child. This technique helps familiarize the child with medical equipment in a non-threatening way, empowering them to feel more in control of the environment. Options A, B, and D may be helpful but do not directly address the child's exposure and interaction with the hospital environment, making them less effective in reducing stress in this context.

4. Upon assessing a newborn immediately after delivery, you note that the infant is breathing spontaneously and has a heart rate of 80 beats/min. What is the MOST appropriate initial management for this newborn?

• A. Assess the newborn's skin condition and color.
• B. Initiate positive-pressure ventilations.
• C. Start chest compressions and contact medical control.
• D. Provide blow-by oxygen with oxygen tubing.

Correct answer: B

Rationale: In a newborn with a heart rate below 100 beats/min, the most appropriate initial management is to initiate positive-pressure ventilations. This helps support the newborn's respiratory effort and oxygenation in the setting of a low heart rate, ensuring adequate oxygen supply to vital organs. Assessing the skin condition and color, starting chest compressions, or providing blow-by oxygen are not the priority in this scenario where respiratory support is crucial.

5. The nurse is preparing to administer vitamin K to a newborn. The mother asks why this injection is necessary. What is the nurse's best response?

• A. It helps the baby's liver function properly.
• B. It prevents bleeding disorders in the newborn.
• C. It boosts the baby's immune system.
• D. It promotes the baby's growth and development.

Correct answer: B

Rationale: The correct answer is B. Vitamin K is administered to newborns to prevent bleeding disorders since they have low levels of vitamin K, which is essential for blood clotting. By providing this injection, the nurse ensures that the newborn has an adequate supply of vitamin K to support proper blood clotting and prevent potential bleeding complications. Choices A, C, and D are incorrect because vitamin K's primary role in newborns is related to blood clotting and preventing bleeding, not liver function, immune system, or growth and development.

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