Nursing Elites

1. You have arrived for your shift on the children's ward and need to assess a 2-year-old who is accompanied by his father. Identify the appropriate strategy to successfully complete a focused assessment:

• A. Allow the child to inspect the equipment for faults before and during assessment
• B. Ask parent to leave room until assessment has been completed
• C. Perform traumatic or invasive procedures first
• D. Have the child sit in parents lap and request assistance if necessary

Correct answer: D

Rationale: Having the child sit in parent's lap can help reduce anxiety and allow for a more accurate assessment.

2. A healthcare provider is educating a new mother on discharge. They told the mother to look for the following danger signs.

• A. Poor Feeding
• B. High Temperature
• C. Convulsions
• D. All of the Above

Correct answer: D

Rationale: It is crucial for new mothers to be aware of potential danger signs after discharge. Poor feeding, high temperature, and convulsions are all critical symptoms that should prompt immediate medical attention. Poor feeding may indicate issues with feeding or underlying health problems. High temperature could be a sign of infection or illness. Convulsions are a serious symptom that could indicate neurological problems or other medical emergencies. By being vigilant and recognizing these signs early, the mother can help ensure the well-being of her newborn. Therefore, the correct answer is 'All of the Above' as all these signs require prompt medical attention to ensure the baby's health and safety.

3. Which of the following signs or symptoms is more common in children than adults following an isolated head injury?

• A. Changes in pupillary reaction
• B. Tachycardia and diaphoresis
• C. Nausea and vomiting
• D. Altered mental status

Correct answer: C

Rationale: Nausea and vomiting are more common in children than adults following an isolated head injury. Children often present with gastrointestinal symptoms like nausea and vomiting after a head injury due to differences in physiological responses compared to adults.

4. A 4-year-old boy with a tracheostomy tube is experiencing respiratory distress. He has intercostal retractions, a heart rate of 80 beats/min, and an oxygen saturation of 85%. During his attempts to breathe, a gurgling sound is heard in the tracheostomy tube. You should:

• A. Ventilate through the tracheostomy tube.
• B. Place an oxygen mask over the tracheostomy tube.
• C. Remove the tracheostomy tube and clean it.
• D. Carefully suction the tracheostomy tube.

Correct answer: D

Rationale: In this scenario, the 4-year-old boy with a tracheostomy tube is showing signs of respiratory distress, including intercostal retractions, a low heart rate, and decreased oxygen saturation. The gurgling sound indicates a possible airway obstruction. Correctly, the immediate action should be to carefully suction the tracheostomy tube. Suctioning can help clear any secretions or obstructions, thus improving the child's ability to breathe effectively. Ventilating through the tube, placing an oxygen mask over it, or removing and cleaning the tube would not address the potential obstruction and could worsen the respiratory distress.

5. A postpartum client who delivered a healthy newborn is being assessed by a nurse. Which finding would indicate a complication during the early postpartum period?

• A. Moderate lochia rubra
• B. Bradycardia
• C. Elevated blood pressure
• D. Uterine contraction

Correct answer: C

Rationale: An elevated blood pressure in the postpartum period may indicate the onset of preeclampsia, a serious complication that requires immediate medical attention. Preeclampsia is characterized by high blood pressure, protein in the urine, and sometimes swelling in the hands and face. If left untreated, preeclampsia can lead to serious complications for both the mother and the baby. Therefore, it is crucial for healthcare providers to closely monitor blood pressure levels in postpartum clients to promptly address any signs of preeclampsia. Choices A, B, and D are not indicative of a complication during the early postpartum period. Moderate lochia rubra is a normal finding as it indicates the normal discharge of blood and tissue from the uterus after childbirth. Bradycardia, a slow heart rate, is not typically a concern in the absence of other symptoms or signs of distress. Uterine contractions are essential for involution and are expected in the postpartum period.

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