Nursing Elites

1. A parent and 3-month-old infant are visiting the well-baby clinic for a routine examination. What should the nurse include in the accident prevention teaching plan?

• A. Remove small objects from the floor.
• B. Cover electric outlets with safety plugs.
• C. Remove toxic substances from low areas.
• D. Test the temperature of water before bathing.

Correct answer: D

Rationale: Testing the temperature of water before bathing is crucial to prevent burns, which is a significant risk for infants due to their sensitive skin. Infants have delicate skin that can easily be burned by water that is too hot. Testing the water temperature before bathing ensures that the water is at a safe and comfortable level for the infant. While choices A, B, and C are also important in accident prevention, such as reducing choking hazards, preventing electric shocks, and avoiding poisoning, testing the water temperature before bathing is the most immediate and direct action to prevent harm to the infant during bathing.

2. Which of the following techniques represents the most appropriate method of opening the airway of an infant with no suspected neck injury?

• A. lift up the chin and hyperextend the neck
• B. tilt the head back without hyperextending the neck
• C. gently lift the chin while maintaining slight flexion of the neck
• D. perform the technique as you would for an older child or adult

Correct answer: B

Rationale: The correct technique for opening the airway of an infant with no suspected neck injury is to tilt the head back without hyperextending the neck. This method helps to keep the airway open without risking injury to the infant's delicate neck structures. Choice A, lifting up the chin and hyperextending the neck, can potentially harm the infant's neck. Choice C, gently lifting the chin while maintaining slight flexion of the neck, is not as effective as tilting the head back. Choice D is incorrect as infants require a different approach compared to older children or adults due to their anatomical differences.

3. 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 because the condition involves a defect in the pelvic region. Choices A, B, and C are incorrect. Imperforate anus, absence of one kidney, and congenital heart disease are not typically associated with exstrophy of the bladder.

4. A nurse is teaching the parents of a child with a diagnosis of epilepsy about seizure precautions. What should the nurse include in the teaching?

• A. Keep a diary of seizure activity
• B. Administer antiepileptic medication only when a seizure occurs
• C. Restrict the child's activities to prevent seizures
• D. Teach seizure first aid to family members

Correct answer: D

Rationale: Teaching seizure first aid to family members is crucial for ensuring the child's safety during a seizure. Keeping a diary of seizure activity (choice A) is important for tracking patterns and triggers but does not directly relate to immediate safety during a seizure. Administering antiepileptic medication only when a seizure occurs (choice B) is incorrect as medications should be given as prescribed to maintain therapeutic levels. Restricting the child's activities to prevent seizures (choice C) is not an appropriate approach as it may limit the child's quality of life without guaranteeing seizure prevention.

5. When developing the plan of care for a child with burns requiring fluid replacement therapy, what information would the nurse expect to include?

• A. Administration of colloid initially followed by a crystalloid
• B. Determination of fluid replacement based on the type of burn
• C. Administration of most of the volume during the first 8 hours
• D. Monitoring of hourly urine output to achieve less than 1 mL/kg/hr

Correct answer: C

Rationale: The correct answer is C. In fluid replacement therapy for burns, it is crucial to administer most of the volume during the first 8 hours to prevent shock and maintain perfusion. This rapid administration is essential to stabilize the child's condition. Choices A and B are incorrect because the initial fluid replacement in burns typically involves administering crystalloids, not colloids, and the fluid replacement is generally calculated based on the extent of the burn injury, not the type of burn. Choice D is incorrect as monitoring hourly urine output to achieve less than 1 mL/kg/hr is not recommended in burn patients; instead, urine output should be monitored to achieve 1-2 mL/kg/hr in children to ensure adequate renal perfusion.

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