Nursing Elites

1. The nurse is selecting a site to begin an intravenous infusion on a 2-year-old child. The superficial veins on his hand and arm are not readily visible. What intervention should increase the visibility of these veins?

• A. Gently tap over the site.
• B. Apply a cold compress to the site.
• C. Raise the extremity above the level of the body
• D. Use a rubber band as a tourniquet for 5 minutes.

Correct answer: A

Rationale: Gently tapping over the site helps dilate the veins and increase visibility. Applying a cold compress or raising the extremity above the body level constricts the veins, making them harder to access. Prolonged tourniquet use can cause discomfort and venous congestion.

2. Rectal temperatures are indicated in which situation?

• A. In the newborn period
• B. Whenever accuracy is essential
• C. Rectal temperatures are never indicated
• D. When rapid temperature changes are occurring

Correct answer: B

Rationale: Rectal temperatures provide the most accurate measurement of core body temperature and are therefore indicated when accuracy is essential.

3. A mother tells the nurse that she does not want her infant immunized because of the discomfort associated with injections. What should the nurse explain?

• A. This cannot be prevented
• B. Infants do not feel pain as adults do
• C. This is not a good reason for refusing
• D. A topical anesthetic can be applied

Correct answer: D

Rationale: The nurse should explain that a topical anesthetic can be applied to the injection site before the immunization to reduce discomfort.

4. 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.

5. What interventions should be implemented to maintain the skin integrity of a preterm infant born at 30 weeks?

• A. Avoid cleaning the skin
• B. Bathe the infant with sterile water
• C. Cleanse the skin with a gentle alkaline-based soap and water
• D. Thoroughly rinse the skin with plain water after bathing

Correct answer: B

Rationale: The correct intervention to maintain the skin integrity of a preterm infant born at 30 weeks is to bathe the infant with sterile water. Bathing with sterile water or a neutral pH solution is recommended to protect the delicate skin of preterm infants, which is more permeable and prone to damage. Choices A, C, and D are incorrect as avoiding cleaning the skin may lead to hygiene issues, cleansing with alkaline-based soap can be harsh on the delicate skin, and thoroughly rinsing with plain water after bathing may not be as gentle and protective for preterm infants.

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