Nursing Elites

1. The nurse determines that a child's intravenous infusion has infiltrated. The infused solution is a vesicant. What is the most appropriate nursing action?

• A. Stop the infusion and apply ice.
• B. End the infusion and notify the practitioner.
• C. Slow the infusion rate and notify the practitioner.
• D. Discontinue the infusion and apply warm compresses.

Correct answer: B

Rationale: If a vesicant solution infiltrates, stopping the infusion immediately and notifying the practitioner is critical to prevent tissue damage. Cold or warm compresses should only be applied following specific medical advice based on the vesicant involved.

2. According to Piaget, a 6-month-old infant should be in which developmental stage?

• A. Use of reflexes
• B. Primary circular reactions
• C. Secondary circular reactions
• D. Coordination of secondary schemata

Correct answer: C

Rationale: By 6 months, infants are usually in the stage of secondary circular reactions, where they start to intentionally repeat actions that bring pleasure or interesting results.

3. What is the typical presentation of pyloric stenosis in infants?

• A. Bilious vomiting
• B. Projectile vomiting
• C. Blood in stools
• D. Failure to thrive

Correct answer: B

Rationale: The correct answer is B: Projectile vomiting. Pyloric stenosis in infants typically presents with projectile vomiting, which is forceful and projective in nature. This occurs due to the obstruction at the pylorus, leading to the stomach being unable to empty properly. Choices A, C, and D are incorrect. Bilious vomiting is more commonly associated with intestinal obstruction, blood in stools can occur in conditions such as necrotizing enterocolitis or allergic colitis, and failure to thrive is a nonspecific finding that can be seen in various pediatric conditions.

4. During examination of a toddler's extremities, the nurse notes that the child is bowlegged. The nurse should recognize that this finding is which?

• A. Abnormal and requires further investigation
• B. Abnormal unless it occurs in conjunction with knock-knee
• C. Normal if the condition is unilateral or asymmetric
• D. Normal because the lower back and leg muscles are not yet well developed

Correct answer: D

Rationale: Bowleggedness is normal in toddlers due to the development of lower back and leg muscles. It usually resolves as the child grows.

5. A nurse is carrying on a conversation with a 7-year-old child during an office visit. Which is an example of the level of language development the nurse should expect in this child?

• A. Fascination with bathroom language
• B. Difficulty understanding the concept of 'half past' in reference to time
• C. Ability to carry on an adult conversation
• D. Inability to speak in full sentences

Correct answer: B

Rationale: The correct answer is B. Understanding time concepts like 'half past' can be challenging for a 7-year-old, indicating the level of language development. Choice A is incorrect as fascination with bathroom language is common in this age group but not necessarily indicative of language development. Choice C is incorrect as a 7-year-old typically cannot carry on an adult conversation due to cognitive and experiential limitations. Choice D is incorrect as by the age of 7, children should be able to speak in full sentences.

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