Nursing Elites

1. A child sitting on a chair in a playroom starts to have a tonic-clonic seizure with a clenched jaw. What is the nurse’s best initial action?

• A. Attempt to open the jaw.
• B. Place the child on the floor.
• C. Call out for assistance from staff.
• D. Place a pillow under the child’s head.

Correct answer: B

Rationale: The best initial action during a tonic-clonic seizure is to place the child on the floor. This action helps prevent injury by providing a safe environment and allows for better management of the seizure episode. Attempting to open the jaw is not recommended as it may cause harm to the child or the nurse. Calling out for assistance is important but should not delay ensuring the child's safety first. Placing a pillow under the child's head is not advisable during a seizure as it can pose a risk of suffocation or choking.

2. When you attempt to assess a 22-year-old woman who has been sexually assaulted, and she orders you not to touch her, your most appropriate initial action should be to

• A. ask the patient to sign a release form
• B. ask a female EMT-B to attempt to assess the patient
• C. explain to the patient that she must be examined
• D. transport the patient without performing an assessment

Correct answer: B

Rationale: In cases of sexual assault, it is crucial to prioritize the patient's emotional and physical comfort. Asking a female EMT-B to attempt the assessment is the most appropriate initial action as it respects the patient's need for privacy and comfort. Asking the patient to sign a release form (Choice A) is not the immediate concern when the patient's well-being and comfort are at stake. Explaining to the patient that she must be examined (Choice C) disregards her autonomy and can worsen the trauma she is experiencing. Transporting the patient without performing an assessment (Choice D) neglects the necessary evaluation and potentially vital care that she may require.

3. A healthcare provider is preparing a 2-year-old child for surgery. What preoperative teaching should be provided to this child?

• A. Explaining the procedure in simple terms
• B. Using a doll to demonstrate the procedure
• C. Showing pictures of the hospital environment
• D. Allowing the child to play with medical equipment

Correct answer: B

Rationale: Using a doll to demonstrate the procedure is the most appropriate preoperative teaching method for a 2-year-old child. It helps them understand what to expect in a non-threatening way by providing a visual representation of the upcoming surgery. Explaining the procedure in simple terms may be too abstract for a child of this age, as they may not fully comprehend verbal explanations. Showing pictures of the hospital environment may not be as effective as using a doll, as it may not provide a concrete understanding of the actual procedure. Allowing the child to play with medical equipment is unsafe and does not adequately prepare them for the surgery, as it may lead to misunderstandings or fear regarding the equipment's actual use during the surgery.

4. Why should the nurse closely monitor the IV flow rate for a 5-month-old infant with severe diarrhea receiving IV fluids?

• A. Maintaining electrolyte balance
• B. Preventing dehydration
• C. Preventing fluid overload
• D. Avoiding cardiac overload

Correct answer: C

Rationale: In infants, monitoring IV flow rates is essential to prevent fluid overload, not cardiac overload. Excessive fluid administration can lead to complications such as pulmonary edema or congestive heart failure. It is crucial to maintain a balance between providing adequate hydration and avoiding fluid overload to prevent adverse outcomes. Options A, B, and D are incorrect because the primary concern is to prevent complications related to excess fluid rather than focusing on electrolyte balance, dehydration prevention, or avoiding cardiac overload.

5. An additional defect is associated with exstrophy of the bladder. For what anomaly should the nurse assess the infant?

• A. Imperforate anus
• B. Absence of one kidney
• C. Congenital heart disease
• D. Pubic bone malformation

Correct answer: D

Rationale: The correct answer is D: Pubic bone malformation. Exstrophy of the bladder is commonly associated with pubic bone malformation as the condition involves a defect in the pelvic region. Imperforate anus, absence of one kidney, and congenital heart disease are not typically associated with exstrophy of the bladder, making them incorrect choices. Therefore, the nurse should primarily assess the infant for pubic bone malformation in this case.

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