Nursing Elites

1. The nurse is presenting a staff development program about understanding culture in the healthcare encounter. Which components should the nurse include in the program? (Select all that apply.)

• A. Cultural humility
• B. All are applicable
• C. Cultural sensitivity
• D. Cultural competency

Correct answer: B

Rationale: Cultural humility, sensitivity, and competency are key components in providing culturally competent care in healthcare encounters.

2. At an 8-month-old well-baby visit, the parent tells the nurse that her infant falls asleep at night during the last bottle feeding but wakes up when moved to the infant’s crib. What is the most appropriate response for the nurse to make?

• A. You should put your baby to sleep 1 hour earlier without the nighttime feeding but with a pacifier for soothing.
• B. You could place rice cereal in the last bottle feeding of the day to ensure a longer sleep pattern.
• C. You should have your partner give the last bottle of the day and observe whether your infant stays awake for your partner.
• D. You could increase daytime feeding intervals to every 4 hours and put your baby in the crib while the baby is still awake.

Correct answer: D

Rationale: Encouraging the baby to fall asleep in the crib while still awake can help establish healthy sleep habits and reduce night waking.

3. What is the most appropriate action for a child with epistaxis?

• A. Have the child lie flat
• B. Pinch the nose and lean forward
• C. Apply a warm compress to the nose
• D. Encourage deep breathing

Correct answer: B

Rationale: The most appropriate action for a child with epistaxis is to pinch the nose and lean forward. This technique helps stop the bleeding and prevent aspiration of blood. By applying pressure to the bleeding vessels and allowing the blood to drain out of the nostrils instead of being swallowed, the risk of nausea and airway obstruction is reduced. Having the child lie flat (Choice A) may lead to blood flowing down the throat, causing potential choking. Applying a warm compress (Choice C) is not typically recommended for epistaxis as cold compresses are more effective. Encouraging deep breathing (Choice D) is not directly related to managing epistaxis.

4. 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.

5. A 6-month-old infant with Hirschsprung disease is scheduled for a temporary colostomy. What should postoperative teaching to the parents include?

• A. Dilating the stoma
• B. Assessing bowel function
• C. Limitation of physical activities
• D. Measures to prevent prolapse of the rectum

Correct answer: B

Rationale: Postoperative teaching should focus on assessing bowel function to ensure the colostomy is functioning properly. This includes monitoring stool output, color, consistency, and signs of infection or blockage. Choice A, dilating the stoma, is not recommended without healthcare provider guidance, as it can lead to complications. Choice C, limitation of physical activities, may not be as crucial immediately after colostomy creation. Choice D, measures to prevent prolapse of the rectum, is more relevant for conditions like rectal prolapse and not specifically for a colostomy.

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