Nursing Elites

1. Examination of the abdomen is performed correctly by the nurse in which order?

• A. Inspection, palpation, percussion, and auscultation
• B. Inspection, percussion, auscultation, and palpation
• C. Palpation, percussion, auscultation, and inspection
• D. Inspection, auscultation, percussion, and palpation

Correct answer: D

Rationale: The correct order for abdominal examination is inspection, auscult

2. Several types of long-term central venous access devices are used. What is a benefit of using an implanted port (e.g., Port-a-Cath)?

• A. You do not need to pierce the skin for access.
• B. It is easy to use for self-administered infusions.
• C. The patient does not need to limit regular physical activity, including swimming.
• D. The catheter cannot dislodge from the port even if the child plays with the port site.

Correct answer: C

Rationale: Implanted ports like the Port-a-Cath are fully implanted under the skin, allowing the child to maintain regular physical activities, including swimming, without the risk of dislodging the catheter. Piercing the skin is still required for access, and self-administration is more complex.

3. What is often the initial sign of acute rheumatic fever in children?

• A. Polyarthritis
• B. Carditis
• C. Erythema marginatum
• D. Sydenham chorea

Correct answer: A

Rationale: Polyarthritis is indeed frequently the initial sign of acute rheumatic fever in children. It presents as joint pain, swelling, and redness. Carditis (inflammation of the heart), Erythema marginatum (a skin rash), and Sydenham chorea (involuntary muscle movements) are typically seen in the later stages of acute rheumatic fever and not as the initial sign.

4. An infant is diagnosed with a tracheoesophageal fistula. Which assessment finding should the nurse expect?

• A. Jaundice
• B. Hyperactive bowel sounds
• C. Absence of sucking, vomiting
• D. Coughing, with excessive secretion

Correct answer: D

Rationale: Coughing with excessive secretion is a common sign of tracheoesophageal fistula. In this condition, the connection between the trachea and esophagus allows saliva and food to enter the airways, leading to coughing and excessive secretions. Choice A, jaundice, is not typically associated with tracheoesophageal fistula. Hyperactive bowel sounds (Choice B) are more likely seen in conditions like gastroenteritis. Absence of sucking and vomiting (Choice C) is not a typical finding related to tracheoesophageal fistula.

5. Which characteristic best describes the fine motor skills of an infant at age 5 months?

• A. Neat pincer grasp
• B. Strong grasp reflex
• C. Builds a tower of two cubes
• D. Able to grasp object voluntarily

Correct answer: D

Rationale: By 5 months, infants develop the ability to grasp objects voluntarily, showing improved motor control. The neat pincer grasp and building towers are skills that develop later.

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