Nursing Elites

1. During the 2-month well-child checkup, the nurse expects the infant to respond to sound in which manner?

• A. Respond to name
• B. React to loud noise with Moro reflex
• C. Turn his or her head to side when sound is at ear level
• D. Locate sound by turning his or her head in a curving arc

Correct answer: B

Rationale: At 2 months, infants typically react to loud noises with the Moro reflex, a startle response that is normal at this stage of development.

2. An intravenous line is needed in a school-age child. What medication is an appropriate analgesic for use with this patient?

• A. TAC (tetracaine, epinephrine [Adrenalin], cocaine) 15 minutes before the procedure.
• B. A transdermal fentanyl (Duragesic) patch at the site of venipuncture.
• C. EMLA (eutectic mixture of local anesthetics) immediately before the procedure.
• D. LMX (4% liposomal lidocaine cream) 30 minutes before the procedure.

Correct answer: D

Rationale: LMX is an effective analgesic agent when applied to the skin 30 minutes before a procedure. It eliminates or reduces the pain from most procedures involving skin puncture. TAC provides skin anesthesia about 15 minutes after application to nonintact skin, making it more suitable for wound suturing. Transdermal fentanyl patches are designed for continuous pain control, not rapid pain control needed for a procedure like venipuncture. EMLA, for maximum effectiveness, must be applied approximately 60 minutes before the procedure, making it less suitable for immediate pain relief required for intravenous line placement.

3. The nurse is administering the first hepatitis A vaccine to an 18-month-old child. When should the child return to the clinic for the second dose of hepatitis A vaccination?

• A. After 2 months
• B. After 3 months
• C. After 4 months
• D. After 6 months

Correct answer: D

Rationale: The second dose of the hepatitis A vaccine is recommended 6 months after the first dose to ensure full immunity.

4. The nurse is preparing to perform a physical assessment on a 10-year-old girl. The nurse gives her the option of her mother staying in the room or leaving. This action should be considered which?

• A. Appropriate because of the child's age
• B. Appropriate, but the mother may be uncomfortable
• C. Inappropriate because of the child's age
• D. Inappropriate because the child is the same sex as the mother

Correct answer: A

Rationale: It is appropriate to give a 10-year-old the choice of having a parent present or not during an exam, respecting the child's growing need for privacy.

5. What amount of fluid loss occurs with moderate dehydration?

• A. <50 ml/kg
• B. 50 to 90 ml/kg
• C. <5% total body weight
• D. >15% total body weight

Correct answer: B

Rationale: Moderate dehydration is typically defined as a loss of 50 to 90 mL/kg of body weight. This amount reflects significant fluid loss that requires medical attention but is not yet severe.

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