Nursing Elites

1. The nurse is conducting discharge teaching to an adolescent with a methicillin-resistant Staphylococcus aureus (MRSA) infection. What should the nurse include in the instructions?

• A. Avoid sharing of towels and washcloths
• B. All are applicable
• C. Use bleach when laundering towels and washcloths
• D. Take a daily bath or shower with an antibacterial soap

Correct answer: B

Rationale: Avoiding sharing of towels and washcloths, using bleach when laundering, and taking daily baths with antibacterial soap are critical to prevent the spread of MRSA. Cold water is not effective for laundering in these cases.

2. What is the most consistent and commonly used indicator of pain in infants?

• A. Increased respirations
• B. Increased heart rate
• C. Thrashing of arms and legs
• D. Facial expression of discomfort

Correct answer: D

Rationale: Facial expression has consistently been validated as an indicator of pain in infants. Behavioral pain measures are most reliable for sharp procedural pain in infants. Increased heart rate and respirations are indicative of a generalized and complex response to stress, not specific for pain in infants. Thrashing of arms and legs is a reliable indicator in young children, not specifically in infants.

3. 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.

4. After the family, which has the greatest influence on providing continuity between generations?

• A. Race
• B. School
• C. Social Class
• D. Government

Correct answer: B

Rationale: Schools play a significant role in providing continuity between generations by imparting cultural values, social norms, and knowledge to children.

5. A 5-year-old has patient-controlled analgesia (PCA) for pain management after abdominal surgery. What information does the nurse include in teaching the parents about the PCA?

• A. The child may not be pain-free.
• B. The parents or nurse may push the button for a bolus if needed.
• C. The pump allows for a continuous basal rate to deliver a constant amount of medication for pain control.
• D. Monitoring is required every 1 to 2 hours to assess patient response.

Correct answer: C

Rationale: The correct answer is C because the PCA pump can be programmed to deliver a continuous basal rate of pain medication to maintain pain control. While the goal of PCA is effective pain relief, it does not guarantee a pain-free state. In the case of a 5-year-old child, the parents or nurse can administer boluses if necessary since the child may not fully comprehend using the PCA button. Monitoring every 1 to 2 hours for patient response is adequate and there is no need for monitoring every 15 minutes, as stated in choice D, unless specific circumstances dictate more frequent monitoring.

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