Nursing Elites

1. An order is written for an isotonic enema for a 2-year-old child. What is the maximum amount of fluid the nurse should administer without a specific order from the health care provider?

• A. 100 to 150 mL
• B. 155 to 250 mL
• C. 255 to 360 mL
• D. 365 to 500 mL

Correct answer: B

Rationale: For a 2-year-old child, the maximum recommended amount of fluid for an isotonic enema is between 155 to 250 mL to prevent overdistension and potential harm. Choice A (100 to 150 mL) is too low and may not be effective in achieving the desired outcome. Choices C (255 to 360 mL) and D (365 to 500 mL) exceed the safe range for a 2-year-old child and can lead to overdistension, electrolyte imbalance, or other complications. Therefore, the correct answer is B.

2. A child with a diagnosis of leukemia is admitted to the hospital with a fever. What is the priority nursing intervention?

• A. Administering antibiotics
• B. Administering antipyretics
• C. Providing nutritional support
• D. Monitoring for signs of infection

Correct answer: D

Rationale: The priority nursing intervention for a child with leukemia admitted to the hospital with a fever is to monitor for signs of infection. Children with leukemia are immunocompromised, making them more susceptible to infections. Monitoring for signs of infection helps in early detection and timely intervention, which is crucial in preventing complications. Administering antibiotics (choice A) may be necessary if an infection is suspected or confirmed, but the priority is to assess for signs of infection first. Administering antipyretics (choice B) may help reduce fever, but it does not address the underlying cause, which could be an infection. Providing nutritional support (choice C) is important for overall health but is not the priority when a child with leukemia presents with a fever, as infection needs to be ruled out or managed first.

3. A nurse is developing a teaching plan for an 8-year-old child who has recently been diagnosed with type 1 diabetes. What developmental characteristic of a child this age should the nurse consider?

• A. Child is in the concrete operational stage of cognition.
• B. Child’s dependence on peer influence is increasing.
• C. Child will welcome opportunities for participation in self-care.
• D. Child’s developmental stage involves achieving a sense of autonomy.

Correct answer: C

Rationale: The correct answer is C. At the age of 8, children are typically in the stage of industry vs. inferiority according to Erikson's psychosocial theory. This stage is characterized by a desire to engage in productive activities and take on responsibilities. Thus, the child will likely welcome opportunities for participation in self-care related to their diabetes management. Choices A, B, and D are incorrect. Choice A is inaccurate as children at this age are usually in the concrete operational stage of cognitive development, not abstract. Choice B is incorrect because while peer influence is significant, it has not reached its peak at this age. Choice D is wrong as achieving a sense of identity is a developmental task more commonly associated with adolescence, not 8-year-old children.

4. The nurse is caring for a child who 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 effectively managing pain during a sickle cell crisis. This initial step helps the nurse understand the severity of the pain, which guides subsequent interventions. Administering medications, such as NSAIDs or meperidine, should only be done after a thorough pain assessment to ensure appropriate and individualized treatment. Using guided imagery and therapeutic touch may be beneficial as adjunct interventions, but they should not replace the essential first step of assessing the pain level accurately.

5. You are caring for a 6-year-old child with a possible fractured left arm and have reason to believe that the child was abused. How should you manage this situation?

• A. Inform the parents of your suspicions.
• B. Call the police so the parents can be arrested.
• C. Advise the parents that the child needs to be transported.
• D. Transport the child to the hospital regardless of the parents' wishes.

Correct answer: C

Rationale: In cases where child abuse is suspected, it is crucial to prioritize the safety and well-being of the child. Advising the parents that the child needs to be transported allows for the child to receive necessary medical care without immediate confrontation. Calling the police to have the parents arrested (Choice B) may escalate the situation and should only be done after ensuring the child's safety. Informing the parents of suspicions (Choice A) may potentially place the child at further risk if the parents are the abusers. Transporting the child to the hospital regardless of the parents' wishes (Choice D) could lead to legal and ethical complications; it is important to involve the appropriate authorities and handle the situation with sensitivity and care.

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