Nursing Elites

1. Nurses should be alert for increased fluid requirements in which circumstance?

• A. Fever
• B. Mechanical ventilation
• C. Congestive heart failure
• D. Increased intracranial pressure

Correct answer: A

Rationale: Fever increases metabolic rate, leading to insensible water loss, thus requiring increased fluid intake. Mechanical ventilation, CHF, and increased intracranial pressure generally require fluid restriction rather than increased fluid intake.

2. What interventions would the nurse implement to maintain the skin integrity of a preterm infant born at 30 weeks?

• A. Avoid using alkaline-based soap.
• B. Bathe the infant with sterile water.
• C. Cleanse skin with a gentle alkaline-based soap and water.
• D. Thoroughly rinse skin with plain water after bathing in a mild hexachlorophene solution.

Correct answer: B

Rationale: To maintain the skin integrity of a preterm infant born at 30 weeks, the nurse should bathe the infant with sterile water no more than two or three times per week. The eyes, oral and diaper areas, and pressure points should be cleansed daily. It is essential to avoid using alkaline-based soaps as they might destroy the 'acid mantle' of the skin. Additionally, cleansing with mild solutions and rinsing thoroughly with plain water is recommended to prevent skin irritation and maintain skin integrity. Therefore, options A, C, and D are incorrect as they do not align with the best practices for preterm infant skin care.

3. The nurse is reviewing the importance of role learning for children. The nurse understands that children's roles are primarily shaped by which members?

• A. Peers
• B. Parents
• C. Siblings
• D. Grandparents

Correct answer: B

Rationale: Parents play the primary role in shaping their children's roles and behaviors, especially in early childhood, through modeling, guidance, and expectations.

4. A 12-month-old infant has been diagnosed with failure to thrive (FTT). Which assessment findings does the nurse expect to be documented with this infant?

• A. Fear of strangers
• B. Minimal smiling
• C. Avoidance of eye contact
• D. All of the above

Correct answer: D

Rationale: These behaviors are consistent with FTT and indicate social withdrawal, which is often observed in infants who are not thriving. A wide-eyed gaze and avoidance of eye contact can also indicate developmental delays or emotional disturbances.

5. Which immunization should the nurse include in a teaching session for parents of toddler-age clients to decrease the risk for epiglottitis?

• A. Hepatitis B
• B. Polio
• C. Measles, mumps, and rubella (MMR)
• D. Hemophilus influenzae type B (Hib)

Correct answer: D

Rationale: The correct answer is D, Hemophilus influenzae type B (Hib) vaccine. Hib vaccine is crucial in preventing epiglottitis, a serious respiratory condition caused by Haemophilus influenzae type b bacteria. This vaccine is recommended for toddlers to protect them from developing epiglottitis. Choices A, B, and C are incorrect because while they are important vaccines for children, they do not specifically target the prevention of epiglottitis, unlike the Hib vaccine.

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