Nursing Elites

1. The mother of a 5-year-old boy with a myelomeningocele who has developed a sensitivity to latex is being taught by the nurse. Which response from his mother indicates a need for further teaching?

• A. He needs to wear a medical alert identification.
• B. I will need to inform his caregivers about this.
• C. A product's label always indicates if it is latex-free.
• D. He should avoid all contact with latex.

Correct answer: C

Rationale: Choice C indicates a need for further teaching because not all products are clearly labeled as latex-free. It is essential for the mother to understand that she should not solely rely on product labels to determine latex content. She should be encouraged to verify with manufacturers and consult healthcare providers for accurate information. Choices A, B, and D are correct responses. Wearing a medical alert identification, informing caregivers, and ensuring the boy avoids all contact with latex are crucial steps in managing his sensitivity to latex and preventing potential allergic reactions.

2. When developing the plan of care for a child with burns requiring fluid replacement therapy, what information would the nurse expect to include?

• A. Administration of colloid initially followed by a crystalloid
• B. Determination of fluid replacement based on the type of burn
• C. Administration of most of the volume during the first 8 hours
• D. Monitoring of hourly urine output to achieve less than 1 mL/kg/hr

Correct answer: C

Rationale: The correct answer is C. In fluid replacement therapy for burns, the majority of the volume should be administered within the first 8 hours to prevent shock and maintain perfusion. Choice A is incorrect because crystalloids are typically administered first in fluid resuscitation for burns. Choice B is incorrect as fluid replacement in burn patients is primarily determined by the extent of the burn injury rather than the type of burn. Choice D is incorrect as the goal for hourly urine output in burn patients is generally higher, aiming for 1-2 mL/kg/hr in children to ensure adequate renal perfusion and prevent dehydration.

3. A parent and 4-year-old child who recently emigrated from Colombia arrive at the pediatric clinic. The child has a temperature of 102°F, is irritable, and has a runny nose. Inspection reveals a rash and several small, red, irregularly shaped spots with blue-white centers in the mouth. What illness does the nurse suspect the child has?

• A. Measles
• B. Chickenpox
• C. Fifth disease
• D. Scarlet fever

Correct answer: A

Rationale: The nurse should suspect measles based on the symptoms described, including the presence of Koplik spots (small, red spots with blue-white centers in the mouth). Measles typically presents with fever, irritability, runny nose, and a rash that begins on the face and spreads downward. Chickenpox (choice B) presents with vesicular lesions in different stages of healing and usually starts on the trunk. Fifth disease (choice C) presents with a 'slapped cheek' rash on the face and can cause joint pain. Scarlet fever (choice D) is characterized by a sandpaper-like rash, fever, and strawberry tongue.

4. What intervention best meets a major developmental need of a newborn in the immediate postoperative period?

• A. Giving a pacifier to the newborn
• B. Placing a mobile over the newborn's crib
• C. Providing the newborn with a soft, cuddly toy
• D. Warming the newborn's formula before feeding

Correct answer: A

Rationale: The correct answer is giving a pacifier to the newborn. Sucking is a natural reflex and a source of comfort for newborns, especially postoperatively. Offering a pacifier can help meet their developmental needs by providing comfort and a soothing mechanism. Placing a mobile over the crib (choice B) may provide visual stimulation but does not directly address the newborn's developmental needs for comfort and self-soothing. Providing a soft, cuddly toy (choice C) may offer some comfort but may not be as effective in meeting the specific developmental need for sucking postoperatively. Warming the newborn's formula before feeding (choice D) relates more to feeding practices than directly addressing a major developmental need in the postoperative period.

5. The parents of a 6-month-old infant are concerned about the risk of sudden infant death syndrome (SIDS). What should the nurse recommend to reduce the risk?

• A. Place the infant on their back to sleep
• B. Use a pacifier during sleep
• C. Have the infant sleep on their side
• D. Keep the infant's room cool

Correct answer: A

Rationale: The correct recommendation to reduce the risk of SIDS in infants is to place them on their back to sleep. This sleeping position helps prevent the occurrence of SIDS by maintaining an open airway and reducing the risk of suffocation. Using a pacifier during sleep has also shown some protective effect against SIDS, but it is not as effective as placing the infant on their back. Having the infant sleep on their side is not recommended as it can increase the risk of accidental suffocation. Keeping the infant's room cool does not directly reduce the risk of SIDS.

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