Nursing Elites

1. The nurse suspects that a child has ingested some type of poison. What clinical manifestation would be most suggestive that the poison was a corrosive product?

• A. Tinnitus
• B. Disorientation
• C. Stupor, lethargy, and coma
• D. Edema of the lips, tongue, and pharynx

Correct answer: D

Rationale: Edema of the lips, tongue, and pharynx is a characteristic sign of corrosive poisoning, indicating damage to mucous membranes from ingestion of a caustic substance. Other symptoms may vary depending on the poison but are not as specific to corrosive ingestion.

2. The nurse is caring for a child receiving chemotherapy with the following orders: Zantac 70 mg IV in normal saline 30 mL to infuse over 30 minutes. The nurse should set the infusion pump to deliver how many mL/hour?

• A. 60 mL/hour
• B. 45 mL/hour
• C. 30 mL/hour
• D. 15 mL/hour

Correct answer: A

Rationale: The correct answer is A: 60 mL/hour. The total volume to be infused is 30 mL over 30 minutes. To calculate the infusion rate in mL/hour, divide the total volume by the total time in hours. In this case, 30 mL / 0.5 hours = 60 mL/hour. Choice B, 45 mL/hour, is incorrect as it does not correspond to the calculated infusion rate. Choices C and D, 30 mL/hour and 15 mL/hour respectively, are also incorrect based on the calculation.

3. By which age should the nurse expect that an infant will be able to pull to a standing position?

• A. 5 to 6 months
• B. 7 to 8 months
• C. 11 to 12 months
• D. 14 to 15 months

Correct answer: C

Rationale: Pulling to a standing position typically occurs between 11 to 12 months, marking the progression towards walking.

4. When assessing a preschooler's chest, what should the nurse expect?

• A. Respiratory movements to be chiefly thoracic
• B. Anteroposterior diameter to be equal to the transverse diameter
• C. Retraction of the muscles between the ribs on respiratory movement
• D. Movement of the chest wall to be symmetric bilaterally and coordinated with breathing

Correct answer: D

Rationale: In a preschooler, chest movement should be symmetric and coordinated with breathing, indicating healthy respiratory function.

5. After surgery yesterday for gastroesophageal reflux, the nurse finds that the infant has somehow removed the nasogastric (NG) tube. What nursing action is most appropriate to perform at this time?

• A. Notify the healthcare provider.
• B. Insert a new NG tube for feedings.
• C. Replace the NG tube to maintain gastric decompression.
• D. Leave the NG tube out as it may have been in long enough.

Correct answer: A

Rationale: The most appropriate action for the nurse to take in this situation is to notify the healthcare provider immediately. This is important as the removal of the NG tube can disrupt postoperative care, especially in terms of maintaining gastric decompression. Inserting a new NG tube without practitioner direction can be unsafe and is not within the nurse's scope of practice. Similarly, replacing the NG tube or leaving it out should be decided by the healthcare provider to ensure the infant's safety and appropriate postoperative care.

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