Nursing Elites

1. The nurse is caring for an infant who had surgical repair of a tracheoesophageal fistula 24 hours ago. Gastrostomy feedings have not been started. What do nursing actions related to the gastrostomy tube include?

• A. Keep the tube clamped.
• B. Suction the tube as needed.
• C. Leave the tube open to gravity drainage.
• D. Secure the tube with tape.

Correct answer: C

Rationale: Leaving the gastrostomy tube open to gravity drainage prevents the accumulation of air and fluids, reducing the risk of complications such as vomiting or aspiration in the immediate postoperative period. Keeping the tube clamped or suctioning it can lead to pressure buildup, increasing the risk of complications. Securing the tube with tape is important but not the primary action related to the gastrostomy tube in this case.

2. Which food should be introduced first to a 6-month-old infant?

• A. Fruits
• B. Eggs
• C. Vegetables
• D. Meat

Correct answer: C

Rationale: Vegetables, particularly pureed ones, are often recommended as a first solid food for infants because they are easy to digest and less likely to cause allergies. Fruits can be introduced later due to their natural sweetness, while eggs and meat are typically introduced after fruits and vegetables as they may pose a higher risk of allergies.

3. The nurse on a pediatric unit is writing guidelines for age-specific preparation of children for procedures based on developmental characteristics. What guideline is accurate?

• A. Inform toddlers about an upcoming procedure 2 hours before the procedure is to be performed.
• B. Inform school-age children about an upcoming procedure immediately before the procedure is scheduled to occur.
• C. Discourage parent presence during procedures on infants and toddlers.
• D. Use simple diagrams of anatomy and physiology to explain a procedure to a school-age child.

Correct answer: D

Rationale: Using simple diagrams helps school-age children understand what to expect in a procedure, catering to their developmental level and reducing anxiety. Informing toddlers too early can increase anxiety, and parents' presence is generally comforting, not discouraging.

4. 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.

5. The school nurse suspects a testicular torsion in a young adolescent student. What action should the nurse take?

• A. Place a warm moist pack on the scrotal area.
• B. Instruct the adolescent to lie down and elevate the legs.
• C. Refer the adolescent for immediate medical evaluation.
• D. Suggest that the adolescent wear a scrotum-protecting guard.

Correct answer: C

Rationale: Testicular torsion is a surgical emergency requiring immediate medical evaluation. Applying heat or elevating the legs will not alleviate the torsion, and delaying care can lead to testicular necrosis.

Similar Questions