Nursing Elites

1. The nurse is caring for a very low-birth-weight (VLBW) infant with a peripheral intravenous infusion. What nursing considerations regarding infiltration should be included in planning IV care?

• A. Infiltration is not solely related to the activity level of VLBW infants.
• B. Continuous infusion pumps do not always stop automatically when infiltration occurs.
• C. Hypertonic solutions can cause severe tissue damage if infiltration occurs.
• D. The infusion site should be checked regularly to prevent infiltration-related complications.

Correct answer: C

Rationale: Hypertonic solutions can damage tissues if they leak from the vein due to infiltration. It is crucial to monitor for this complication to prevent severe tissue damage. Infiltration is not solely related to the activity level of VLBW infants; it can occur due to various reasons such as vein condition, catheter placement, and fluid type. Continuous infusion pumps may not always detect infiltration, as they typically alarm for pressure changes but not all infiltration instances. Checking the infusion site regularly, preferably hourly, is essential to prevent complications like tissue damage from extravasations, fluid overload, and dehydration.

2. The nurse is planning to counsel family members as a group to assess the family's group dynamics. Which theoretical family model is the nurse using as a framework?

• A. Feminist theory
• B. Family stress theory
• C. Family systems theory
• D. Developmental theory

Correct answer: C

Rationale: Family systems theory views the family as an interconnected system where changes in one member affect the entire family, making it ideal for assessing group dynamics.

3. A child is admitted with renal failure. Which of these findings should the nurse expect?

• A. Decreased BUN
• B. Azotemia and oliguria
• C. Increased glomerular filtration rate (GFR)
• D. Polyuria and elevated creatinine clearance

Correct answer: B

Rationale: Azotemia (elevated BUN and creatinine) and oliguria (reduced urine output) are classic signs of renal failure, indicating impaired kidney function. In renal failure, the kidneys are unable to effectively filter waste products, leading to an increase in BUN and creatinine levels in the blood. Additionally, oliguria occurs due to decreased kidney function. Increased GFR (Choice C) is not expected in renal failure as it signifies improved kidney function, which is not the case in renal failure. Polyuria and elevated creatinine clearance (Choice D) are not typical findings in renal failure. Polyuria is more commonly associated with conditions like diabetes insipidus, while elevated creatinine clearance would indicate increased kidney function, which is contrary to the impaired function seen in renal failure.

4. The nurse is educating a new nurse on the identification of pain in children. What does the nurse teach about physiologic measurements in children’s pain assessment?

• A. Not useful as the only indicator for pain
• B. Best indicator of pain in children of all ages
• C. Most valuable when children also report having pain
• D. Essential to determine whether a child is telling the truth about pain

Correct answer: A

Rationale: Physiologic manifestations of pain may vary considerably, so they do not provide a consistent measure of pain. Heart rate may increase or decrease. The same signs that may suggest fear, anxiety, or anger also indicate pain. In chronic pain, the body adapts, and these signs decrease or stabilize. Physiologic measurements are of limited value and must be viewed in the context of a pain rating scale, behavioral assessment, and parental report. When the child reports pain on an appropriate pain scale, the appropriate interventions should be used. Therefore, physiologic measurements are not considered a reliable standalone indicator for pain in children, making choice A the correct answer. Choice B is incorrect because physiologic measurements alone do not serve as the best indicator of pain. Choice C is incorrect as physiologic measurements are still limited even when children report pain. Choice D is incorrect as physiologic measurements are not primarily used to determine the truthfulness of a child's pain report.

5. What is the most common symptom of gastroesophageal reflux in infants?

• A. Projectile vomiting
• B. Bilious vomiting
• C. Frequent spitting up
• D. Diarrhea

Correct answer: C

Rationale: Frequent spitting up is indeed a common symptom of gastroesophageal reflux in infants. It is caused by the backward flow of stomach contents into the esophagus, leading to infants regurgitating milk or formula shortly after feeding. Projectile vomiting (choice A) is more commonly associated with conditions like pyloric stenosis rather than gastroesophageal reflux. Bilious vomiting (choice B) often indicates an obstruction in the gastrointestinal tract. Diarrhea (choice D) is not typically a primary symptom of gastroesophageal reflux in infants.

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