Nursing Elites

1. You are called to a residence for a 'sick' 5-year-old child. When you arrive and begin your assessment, you note that the child is unconscious with a respiratory rate of 8 breaths/min and a heart rate of 50 beats/min. Management of this child should consist of

• A. 100% oxygen via a non-rebreathing mask and rapid transport
• B. positive pressure ventilations with a BVM device and rapid transport
• C. chest compressions, artificial ventilations, and rapid transport
• D. back blows and chest thrusts while attempting artificial ventilations

Correct answer: C

Rationale: In a 5-year-old child who is unconscious with a respiratory rate of 8 breaths/min and a heart rate of 50 beats/min, the priority is to initiate chest compressions, artificial ventilations, and rapid transport. These vital interventions are crucial in cases of severe respiratory and cardiovascular compromise. Choice A is incorrect because administering 100% oxygen alone may not address the underlying issues of inadequate ventilation and circulatory support. Choice B is not the most appropriate initial intervention in this scenario; chest compressions should precede positive pressure ventilations. Choice D is incorrect as back blows and chest thrusts are indicated in choking emergencies, not in this case of respiratory and cardiovascular compromise.

2. When caring for a child diagnosed with cystic fibrosis, what is the priority nursing intervention?

• A. Administering pancreatic enzymes
• B. Providing respiratory therapy
• C. Encouraging physical activity
• D. Encouraging frequent handwashing

Correct answer: A

Rationale: The priority nursing intervention when caring for a child with cystic fibrosis is administering pancreatic enzymes. Cystic fibrosis is a genetic disorder that affects the digestive and respiratory systems. Administering pancreatic enzymes is crucial in aiding digestion as patients with cystic fibrosis often have pancreatic insufficiency. While providing respiratory therapy and encouraging physical activity are important aspects of care for individuals with cystic fibrosis, administering pancreatic enzymes takes precedence in addressing the malabsorption issues associated with the condition. Encouraging frequent handwashing is also essential in infection control, but it is not the priority intervention specifically related to managing cystic fibrosis.

3. A child is admitted with extensive burns. The nurse notes burns on the child’s lips and singed nasal hairs. The nurse should suspect that the child has a(n)

• A. chemical burn
• B. inhalation injury
• C. electrical burn
• D. hot-water scald

Correct answer: B

Rationale: Burns on the lips and singed nasal hairs indicate inhalation injury, suggesting the child has inhaled hot gases or smoke. This presentation is common in cases where the respiratory tract is exposed to hot gases or smoke, leading to potential airway compromise. Choice A, chemical burn, is incorrect because there is no mention of exposure to chemicals, and the symptoms described are more indicative of inhalation injury. Choice C, electrical burn, is incorrect as there is no evidence of electrical involvement in the scenario provided. Choice D, hot-water scald, is incorrect because the presence of singed nasal hairs points more towards inhalation injury than a scald from hot water, emphasizing the need to prioritize airway management and respiratory support.

4. An infant who had cardiac surgery for a congenital defect is to be discharged. What should the nurse emphasize to the parents regarding administering the prescribed antibiotic?

• A. Give the antibiotic between feedings.
• B. Ensure that the antibiotic is administered as prescribed.
• C. Shake the bottle thoroughly before administering the antibiotic.
• D. Keep the antibiotic in the refrigerator after opening the bottle.

Correct answer: B

Rationale: The correct answer is B: 'Ensure that the antibiotic is administered as prescribed.' It's crucial to stress the importance of following the prescribed antibiotic regimen to prevent infections and promote proper healing after cardiac surgery. Choice A is incorrect because it does not address the fundamental aspect of adherence to the prescription. Choice C is incorrect as shaking the bottle may not be necessary for all antibiotics and is not a critical instruction in this context. Choice D is incorrect as storage instructions are not directly related to the administration of the antibiotic as prescribed, which is the primary concern in this scenario.

5. The nurse is counseling a young couple who in 2 months are having their third baby. The nurse uses Von Bertalanffy's general system theory applied to families to analyze the family structure. Which best describes the main emphasis of this theory and its application to family dynamics?

• A. It emphasizes the family as a system with interdependent, interacting parts that endure over time to ensure the survival, continuity, and growth of its components.
• B. It emphasizes the social system of the family, such as the organization or structure of the family and how the structure relates to its function.
• C. It emphasizes the developmental stages that all families go through, beginning with marriage; the longitudinal career of the family is also known as the family life cycle.
• D. It addresses how families respond to stress and how the family copes with stress as a group and how each individual member copes.

Correct answer: A

Rationale: Von Bertalanffy's general system theory applied to families emphasizes the family as a system with interdependent, interacting parts that endure over time to ensure the survival, continuity, and growth of its components. This theory focuses on viewing the family as a dynamic system where each member's actions and behaviors impact the whole family unit. Choice B is incorrect as it focuses solely on the social system of the family, while Von Bertalanffy's theory looks at the family as a whole system. Choice C is incorrect as it discusses family developmental stages, which is not the main emphasis of Von Bertalanffy's theory. Choice D is also incorrect as it only addresses how families respond to stress, which is a narrower focus compared to the broader system view of Von Bertalanffy's theory.

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