Nursing Elites

1. A child is admitted with suspected pyloric stenosis. Which of the following should be included in the plan of care?

• A. Monitor for signs of metabolic acidosis
• B. Observe for projectile vomiting
• C. Provide large, infrequent feedings to allow for rest
• D. Place the infant in a supine position after feeding

Correct answer: B

Rationale: The correct answer is B: 'Observe for projectile vomiting.' Projectile vomiting is a classic sign of pyloric stenosis, caused by obstruction at the pylorus. Choice A is incorrect as metabolic alkalosis, not acidosis, often occurs due to the loss of hydrochloric acid from persistent vomiting. Choice C is incorrect as frequent, small feedings are preferred to prevent overloading the stomach. Choice D is incorrect as placing the infant in an upright position after feeding can help reduce reflux.

2. What is the most effective method to prevent infection in the newborn?

• A. Using disposable items
• B. Practicing proper hand hygiene by staff and family
• C. Administering prophylactic antibiotics
• D. Isolating the newborn from others

Correct answer: B

Rationale: The most effective method to prevent infection in newborns is by practicing proper hand hygiene by staff and family. This is crucial as it helps reduce the transmission of infectious agents, protecting vulnerable newborns. Using disposable items may help, but proper hand hygiene is more effective. Administering prophylactic antibiotics without a specific indication can lead to antibiotic resistance and is not recommended. Isolating the newborn from others is not practical and may not be necessary if proper hand hygiene is maintained.

3. An anxious 12-year-old child receives an injection from the nurse and sighs with relief when it is done. After a moment of reflection, the girl asks the nurse, 'Is it hard to give someone an injection?' This child’s question is evidence that the child has developed which cognitive skill?

• A. Conservation
• B. Accommodation
• C. Decentering
• D. Class inclusion

Correct answer: C

Rationale: The correct answer is C: Decentering. Decentering is the ability to consider multiple aspects of a situation, which the child's question demonstrates. In this scenario, the child's question shows that she is thinking beyond her own experience and considering the difficulty or complexity of giving an injection from the nurse's perspective. Choices A, B, and D are incorrect. Conservation refers to understanding that certain properties of an object remain the same despite changes in its appearance. Accommodation is the process of adjusting existing knowledge or creating new mental categories to incorporate new information. Class inclusion involves understanding the relationship between a whole set and its subsets, which is not demonstrated in the child's question.

4. The nurse is selecting a site to begin an intravenous infusion on a 2-year-old child. The superficial veins on his hand and arm are not readily visible. What intervention should increase the visibility of these veins?

• A. Gently tap over the site.
• B. Apply a cold compress to the site.
• C. Raise the extremity above the level of the body
• D. Use a rubber band as a tourniquet for 5 minutes.

Correct answer: A

Rationale: Gently tapping over the site helps dilate the veins and increase visibility. Applying a cold compress or raising the extremity above the body level constricts the veins, making them harder to access. Prolonged tourniquet use can cause discomfort and venous congestion.

5. A parent calls the hospital nursing hotline and asks, 'My 8-week-old infant cries 8 hours a day, and is hard to console. Is that normal?' What should the nurse's response be to this parent?

• A. No, call your health care provider.
• B. Let me ask you some more questions to see if there are symptoms of colic.
• C. Yes, maybe your infant is just tired.
• D. Yes, infants cry all the time at that age.

Correct answer: B

Rationale: The correct response for the nurse to provide in this situation is to ask more questions to determine if the infant is displaying symptoms of colic. Colic is a common condition in infants that can lead to prolonged crying and fussiness. It is essential to assess for other symptoms before giving advice to the parent. Choices A, C, and D are incorrect because they do not address the possibility of colic or the need for further assessment of the infant's condition.

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