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. What complication of mumps is crucial for adolescents to prevent?

• A. Sterility
• B. Hypopituitarism
• C. Decreased libido
• D. Decreased androgens

Correct answer: A

Rationale: The correct answer is A, Sterility. Mumps can lead to sterility, particularly in adolescent males, highlighting the significance of vaccination to prevent this serious complication. While hypopituitarism (choice B) can be a potential complication of mumps, it is not as crucial to prevent in adolescents compared to the risk of sterility. Choices C and D, Decreased libido and Decreased androgens, are not direct complications of mumps and are not the primary concerns for adolescents in relation to mumps prevention.

3. 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.

4. After clearing the airway of a newborn who is not in distress, what is the most important action to take next?

• A. Administer free-flow oxygen
• B. Clamp and cut the cord
• C. Keep the newborn warm
• D. Obtain an APGAR score

Correct answer: C

Rationale: Keeping the newborn warm is crucial immediately after clearing the airway to prevent hypothermia, which can lead to complications in newborns. Administering free-flow oxygen is not necessary if the newborn is not in distress. Clamping and cutting the cord can be done after ensuring the newborn's warmth. Obtaining an APGAR score is important but can be done after ensuring the newborn is kept warm and stable.

5. The parents of a child who has just been diagnosed with type 1 diabetes ask about exercise. What should the nurse explain about exercise in type 1 diabetes?

• A. Exercise will increase blood glucose levels
• B. Exercise should be restricted
• C. Extra snacks are needed before exercise
• D. Extra insulin is required during exercise

Correct answer: C

Rationale: In type 1 diabetes, extra snacks are needed before exercise to prevent hypoglycemia. It is important to provide additional carbohydrates to maintain blood glucose levels during physical activity. Choices A, B, and D are incorrect. Exercise typically lowers blood glucose levels in individuals with diabetes; however, proper management and adjustments in insulin and food intake are necessary to prevent hypoglycemia. Exercise should not be restricted in individuals with type 1 diabetes but should be planned in coordination with healthcare providers to ensure safety and optimal glucose control. While some individuals may need adjustments in insulin dosages during exercise, the general statement that extra insulin is required during exercise in type 1 diabetes is not accurate.

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