Nursing Elites

1. A nurse in an emergency department is caring for a school-age child who is experiencing an anaphylactic reaction. Which of the following is the priority action by the nurse?

• A. Elevate the head of the child's bed
• B. Insert a large-bore IV catheter for the child
• C. Determine the allergen that caused the child's reaction
• D. Administer IM epinephrine to the child

Correct answer: D

Rationale: In the management of anaphylaxis, the priority action for the nurse is to administer IM epinephrine to the child. Epinephrine is the first-line treatment for anaphylaxis as it helps reverse the severe manifestations of the reaction by constricting blood vessels, relaxing airway muscles, and decreasing hives and swelling. Elevating the head of the child's bed may be beneficial for respiratory distress but is not the priority over administering epinephrine. Inserting a large-bore IV catheter may be necessary for fluid resuscitation but is not the initial priority. Identifying the allergen is important for prevention and future management but is not the immediate action needed in the acute phase of an anaphylactic reaction.

2. When teaching a school-age child and the parent how to administer insulin, which of the following instructions should the nurse include?

• A. Store the insulin in the refrigerator after each use.
• B. Rotate injection sites each time you give the injection.
• C. You should give the insulin at room temperature.
• D. Administer the insulin within 30 minutes of each meal.

Correct answer: C

Rationale: It is essential to give insulin at room temperature to prevent discomfort during administration. Cold insulin can cause stinging and pain, which can be avoided by allowing the insulin to reach room temperature before administration. Storing insulin in the refrigerator is correct for long-term storage, but it should be brought to room temperature before use. Rotating injection sites is important to prevent lipohypertrophy, a condition characterized by fatty lumps that can develop if injections are consistently given in the same area. Administering insulin within 30 minutes of a meal is generally recommended to match the insulin peak action with the peak glucose levels after eating, but giving insulin at room temperature is more crucial to ensure comfort and proper absorption.

3. What does a Z-score of -3.00 indicate?

• A. The child's score indicates he is ahead of his peers and performing well
• B. The child's score places him within normal limits on this test item
• C. The test is inconclusive
• D. The child's score falls below the majority of his peers on this test

Correct answer: D

Rationale: A Z-score of -3.00 indicates that the child's performance is significantly below the average of their peers. It represents an extreme low score, indicating a substantial deviation from the mean performance of the group.

4. A parent of a child with oral candidiasis is being taught by a nurse. Which statement by the parent indicates an understanding of the teaching?

• A. I will boil the nipples and pacifiers for 20 minutes each day.
• B. I will stop the medication as soon as the spots disappear.
• C. I will apply an over-the-counter steroid cream to the spots.
• D. I will mix the medication in my child's bottle.

Correct answer: A

Rationale: Boiling the nipples and pacifiers for 20 minutes each day is an appropriate measure to prevent reinfection of oral candidiasis. This practice helps eliminate the Candida fungus from these items, reducing the risk of the child getting reinfected. It is crucial for the parent to follow this hygienic practice consistently to ensure the child's recovery and prevent the spread of the infection.

5. During a well-child visit, a nurse is assessing a three-year-old toddler. Which of the following manifestations should the nurse report to the provider?

• A. Blood pressure 90/50
• B. Respiratory rate 45/min
• C. Weight 14.5 kg or 32 lb
• D. Heart rate 110/min

Correct answer: B

Rationale: A respiratory rate of 45/min is above the expected reference range for a 3-year-old toddler and may indicate respiratory dysfunction or acute respiratory distress. It is essential for the nurse to report this finding promptly to the healthcare provider for further evaluation and intervention.

Similar Questions