Nursing Elites

1. The nurse is preparing to give acetaminophen (Tylenol) to a child who has a fever. What nursing action is appropriate?

• A. Retake the temperature in 15 minutes after giving the Tylenol.
• B. Place a warm blanket on the child so chilling does not occur.
• C. Check to be sure the Tylenol dose does not exceed 15 mg/kg.
• D. Use cold compresses instead of Tylenol to control the fever.

Correct answer: C

Rationale: Ensuring the dose does not exceed 15 mg/kg is critical to avoid overdose and potential liver damage. Retaking the temperature immediately or using cold compresses is not necessary, and placing a warm blanket could exacerbate the fever.

2. The nurse is preparing to assess a 10-month-old infant. He is sitting on his father's lap and appears to be afraid of the nurse and of what might happen next. Which initial actions by the nurse should be most appropriate?

• A. Initiate a game of peek-a-boo.
• B. Ask the infant's father to place the infant on the examination table
• C. Talk softly to the infant while taking him from his father
• D. Undress the infant while he is still sitting on his father’s lap

Correct answer: A

Rationale: Engaging the infant in a familiar game like peek-a-boo can help reduce fear and build rapport before starting the assessment.

3. Apgar scoring is conducted at 1 minute and 5 minutes after birth. It is used to determine:

• A. Major body systems’ responses at birth
• B. Future intelligence of the newborn
• C. Level of parent and newborn interaction
• D. Gestational age of the newborn

Correct answer: A

Rationale: The Apgar score assesses a newborn's physical condition immediately after birth by evaluating heart rate, respiratory effort, muscle tone, reflex response, and color. Therefore, the correct answer is A. The other choices are incorrect because B) the Apgar score does not predict future intelligence, C) it does not measure parent and newborn interaction, and D) it is not used to determine gestational age.

4. Which intervention is the most appropriate recommendation for relief of teething pain?

• A. Rub gums with aspirin to relieve inflammation
• B. Apply hydrogen peroxide to gums to relieve irritation
• C. Give the infant a frozen teething ring to relieve inflammation
• D. Have the infant chew on a warm teething ring to encourage tooth eruption

Correct answer: C

Rationale: A frozen teething ring is effective for relieving teething pain as the cold helps numb the gums and reduce inflammation, making it a safe and effective method for managing discomfort

5. Picking up a pencil demonstrates the ability to use which of the following?

• A. Pincer grasp
• B. Prehension
• C. Parachute reflex
• D. Grasp reflex

Correct answer: A

Rationale: Picking up a pencil requires the use of the pincer grasp, which involves the coordination of the thumb and forefinger to hold small objects. The pincer grasp is a fine motor skill essential for tasks that necessitate precision and dexterity. Choices B, C, and D are incorrect. Prehension refers to the act of grasping or holding an object, parachute reflex is a protective response to sudden movement or loss of support, and grasp reflex is an automatic closing of the hand when an object is placed in the palm, none of which specifically relate to the action of picking up a pencil.

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