Nursing Elites

1. Why might a healthcare provider question a health care provider's order for a tap water enema for a 6-month-old infant with suspected Hirschsprung disease?

• A. The result could lead to loss of necessary nutrients.
• B. It could cause a fluid and electrolyte imbalance.
• C. It could increase the fear of intrusive procedures.
• D. The result could cause shock from a sudden drop in temperature.

Correct answer: B

Rationale: The correct answer is B. Tap water enemas can cause significant fluid and electrolyte imbalances, particularly in infants, making them unsafe for this age group. Choice A is incorrect because tap water enemas are unlikely to lead to loss of necessary nutrients. Choice C is incorrect as it does not directly relate to the physiological risk of tap water enemas. Choice D is incorrect as shock from a sudden drop in temperature is not a common concern with tap water enemas.

2. A newborn is admitted to the neonatal intensive care unit (NICU) with choanal atresia. Which part of the infant’s body should the nurse assess?

• A. Rectum
• B. Nasopharynx
• C. Intestinal tract
• D. Laryngopharynx

Correct answer: B

Rationale: Choanal atresia is a congenital condition that presents with a blockage in the nasal passages at the junction of the nasal cavity and the nasopharynx. To assess and confirm the diagnosis of choanal atresia, the nurse should focus on assessing the nasopharynx. Choices A, C, and D are incorrect as choanal atresia specifically involves a blockage in the nasal passages, not the rectum, intestinal tract, or laryngopharynx. By assessing the nasopharynx, the severity of the obstruction can be determined, aiding in planning appropriate interventions for the newborn.

3. The parents of a 2-year-old child tell the nurse that they are having difficulty disciplining their child. What is the nurse’s most appropriate response?

• A. “This is a difficult age that your child is going through right now.”
• B. “Tell me more about your difficulty. I’m not sure what you mean by this.”
• C. “It’s important to be consistent with toddlers when they need disciplining.”
• D. “I can understand what you mean. That’s why this age is called the terrible twos.”

Correct answer: C

Rationale: The most appropriate response for the nurse is to emphasize the importance of consistency in discipline when dealing with toddlers. Toddlers are at an age where they are learning boundaries and acceptable behaviors. By being consistent, parents can help their child understand what is expected of them and establish a sense of structure and routine. Choices A, B, and D do not provide constructive advice or guidance on how to address the issue of disciplining a 2-year-old. Choice A merely acknowledges the age without providing guidance, choice B seeks more information without offering support, and choice D labels the age without offering practical advice on discipline.

4. A child with acute lymphoblastic leukemia (ALL) is hospitalized for treatment. What is the priority nursing intervention?

• A. Administering antibiotics
• B. Preventing infection
• C. Providing nutritional support
• D. Managing pain

Correct answer: B

Rationale: The priority nursing intervention for a child hospitalized for acute lymphoblastic leukemia (ALL) is preventing infection. Children with ALL have compromised immune systems, making them highly vulnerable to infections. Preventing infections through strict aseptic techniques, isolation precautions, and proper hygiene is crucial to safeguard the child's health. Administering antibiotics (choice A) may be necessary if an infection occurs, but the primary focus should be on infection prevention. While providing nutritional support (choice C) is important, preventing infection takes precedence due to its direct impact on the child's survival. Managing pain (choice D) is essential for the child's comfort but is not the priority over preventing life-threatening infections in this scenario.

5. The nurse is teaching a group of parents about the side effects of immunization vaccines. Which sign should the nurse include when discussing an infant receiving the Haemophilus influenzae (Hib) vaccine?

• A. Lethargy
• B. Urticaria
• C. Generalized rash
• D. Low-grade fever

Correct answer: D

Rationale: The correct answer is 'D. Low-grade fever.' A low-grade fever is a common and mild side effect of the Hib vaccine, indicating that the immune system is responding to the immunization. Lethargy (choice A) can be a sign of more serious adverse effects and should be monitored closely but is not typically associated with the Hib vaccine. Urticaria (choice B) and generalized rash (choice C) are less common side effects of the Hib vaccine compared to low-grade fever.

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