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. A healthcare provider is assessing a child with suspected Kawasaki disease. What clinical manifestation is the healthcare provider likely to observe?

• A. Generalized rash
• B. Peeling skin on the hands and feet
• C. High fever
• D. Low-grade fever

Correct answer: B

Rationale: Peeling skin on the hands and feet is a characteristic clinical manifestation of Kawasaki disease, known as desquamation. This occurs during the convalescent phase of the illness. While Kawasaki disease is associated with a high fever, which is a common early sign, and can also present with other symptoms like conjunctivitis, mucous membrane changes, and lymphadenopathy, the peeling skin on the hands and feet is a classic feature that distinguishes Kawasaki disease from other conditions. Generalized rash is not a specific hallmark of Kawasaki disease, and low-grade fever is not typically associated with this condition. Therefore, the correct answer is B, peeling skin on the hands and feet, which is a key feature of Kawasaki disease.

3. What clinical manifestation of tetralogy of Fallot should the nurse expect when caring for children with this diagnosis?

• A. Slow respirations
• B. Clubbing of fingers
• C. Decreased RBC counts
• D. Subcutaneous hemorrhages

Correct answer: B

Rationale: Clubbing of fingers is a common manifestation in children with tetralogy of Fallot due to chronic hypoxia. Clubbing occurs as a result of long-standing decreased oxygen levels in the blood, leading to changes in the fingertips. Slow respirations (Choice A) are not typically a direct clinical manifestation of tetralogy of Fallot. While decreased RBC counts (Choice C) may occur due to chronic hypoxia, they are not a primary manifestation specific to tetralogy of Fallot. Subcutaneous hemorrhages (Choice D) are not a common clinical manifestation associated with tetralogy of Fallot.

4. The caregiver is teaching the mother of a toddler about burn prevention. Which response by the mother indicates a need for further teaching?

• A. We will leave fireworks displays to the professionals.
• B. I will set our water heater at 130 degrees.
• C. All sleepwear should be flame retardant.
• D. The handles of pots on the stove should face inward.

Correct answer: B

Rationale: The correct answer is B. Setting the water heater at 130 degrees is incorrect because water heaters should be set to no higher than 120 degrees to prevent scald burns. Choice A is correct as leaving fireworks displays to professionals reduces the risk of burns. Choice C is also correct as flame-retardant sleepwear reduces the risk of burn injuries. Choice D is correct as keeping pot handles facing inward prevents accidental spills and burns.

5. When administering IV fluids to a dehydrated infant, what intervention is most important at this time?

• A. Continuing the prescribed flow rate
• B. Monitoring the intravenous drop rate
• C. Calculating the total necessary intake
• D. Maintaining the fluid at body temperature

Correct answer: B

Rationale: Monitoring the intravenous drop rate is the most crucial intervention when administering IV fluids to a dehydrated infant. This ensures that the correct amount of fluids is being delivered to the infant at the appropriate rate. While continuing the prescribed flow rate (Choice A) may be important, it does not allow for real-time adjustments that may be necessary during the infusion. Calculating the total necessary intake (Choice C) should have been determined before initiating IV therapy. Maintaining the fluid at body temperature (Choice D) is important for patient comfort but is not as critical as ensuring the proper administration of fluids.

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