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. The school nurse is caring for a boy with hemophilia who fell on his arm during recess. What supportive measures should the nurse use until factor replacement therapy can be instituted?

• A. Apply warm, moist compresses
• B. Apply pressure for at least 1 minute
• C. Elevate the area above the level of the heart
• D. Begin passive range-of-motion unless the pain is severe

Correct answer: C

Rationale: The correct supportive measure for the school nurse to use for a boy with hemophilia who fell on his arm during recess is to elevate the area above the level of the heart. Elevating the affected area helps reduce bleeding and swelling in a child with hemophilia until factor replacement therapy can be provided. Applying warm, moist compresses (Choice A) may worsen bleeding by dilating blood vessels. Applying pressure for at least 1 minute (Choice B) is not recommended for hemophilia as it can lead to increased bleeding. Beginning passive range-of-motion (Choice D) should be avoided as it can exacerbate bleeding and further injury in a child with hemophilia.

3. The caregiver is teaching the mother of a toddler about burn prevention. Which response by the mother indicates a need for further teaching?

• A. We will leave fireworks displays to the professionals.
• B. I will set our water heater at 130 degrees.
• C. All sleepwear should be flame retardant.
• D. The handles of pots on the stove should face inward.

Correct answer: B

Rationale: Setting the water heater at 130 degrees can lead to scald burns. The recommended temperature setting for water heaters is no higher than 120 degrees to prevent burns. Choice A is correct as it shows awareness of the risks of fireworks. Choice C is correct as flame-retardant sleepwear can help prevent burns. Choice D is correct as inward-facing pot handles prevent accidental spills and burns. Option B is incorrect due to the unsafe water heater temperature setting.

4. A nurse is assessing a 10-month-old infant. What developmental milestone should the nurse expect to observe?

• A. Crawling
• B. Sitting without support
• C. Standing with assistance
• D. Pulling to a stand

Correct answer: D

Rationale: The correct answer is D: Pulling to a stand. By 10 months of age, most infants should be able to pull themselves up to a standing position while holding onto furniture or other support. This milestone indicates good strength and coordination in the lower body. Choice A, Crawling, is typically achieved around 6-9 months of age. Choice B, Sitting without support, usually occurs around 6-8 months. Choice C, Standing with assistance, can typically be seen around 9-12 months, but pulling to a stand is a more advanced milestone expected by 10 months.

5. The child has been admitted for a sickle cell crisis. What would the nurse do first to provide adequate pain management?

• A. Administer a nonsteroidal anti-inflammatory drug (NSAID) as ordered.
• B. Use guided imagery and therapeutic touch.
• C. Administer meperidine as ordered.
• D. Initiate pain assessment with a standardized pain scale.

Correct answer: D

Rationale: Initiating pain assessment with a standardized pain scale is crucial in managing pain effectively during a sickle cell crisis. This step allows the nurse to objectively evaluate the child's pain level and tailor the pain management plan accordingly. Administering medication without a proper assessment could lead to inappropriate pain management. Using guided imagery and therapeutic touch may be beneficial as adjunct therapies but should not replace the initial pain assessment. Meperidine is not typically the first-line choice for pain management in sickle cell crisis due to its potential for neurotoxic metabolites.

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