Nursing Elites

1. What information should be included in the preoperative plan of care for an infant with myelomeningocele?

• A. Positioning the infant supine with a pillow under the buttocks
• B. Covering the sac with saline-soaked nonadhesive gauze
• C. Wrapping the infant snugly in a blanket
• D. Applying a diaper to prevent fecal soiling of the sac

Correct answer: B

Rationale: Covering the sac with saline-soaked nonadhesive gauze is essential in the preoperative care of an infant with myelomeningocele. This practice helps prevent infection and maintains moisture around the sac before surgery, promoting optimal healing outcomes. Positioning the infant supine with a pillow under the buttocks may be uncomfortable and unnecessary. Wrapping the infant snugly in a blanket does not address the specific care needs of the myelomeningocele. Applying a diaper over the sac can increase the risk of infection and should be avoided in this case.

2. When preparing a 2-year-old child for surgery, what preoperative teaching should be provided to help them understand the procedure?

• A. Explaining the procedure in simple terms
• B. Using a doll to demonstrate the procedure
• C. Showing pictures of the hospital environment
• D. Allowing the child to play with medical equipment

Correct answer: B

Rationale: The correct preoperative teaching for a 2-year-old child undergoing surgery involves using a doll to demonstrate the procedure. This method helps the child understand what to expect in a non-threatening and visual way, making the experience less intimidating. Explaining the procedure in simple terms (Choice A) may not effectively convey the details to a young child. Showing pictures of the hospital environment (Choice C) may not directly address the surgical procedure itself. Allowing the child to play with medical equipment (Choice D) can be unsafe and may not effectively prepare the child for the surgery.

3. 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 crucial when administering IV fluids to ensure that the correct amount of fluids is delivered to the dehydrated infant. Choice A assumes the initial rate is correct without ongoing assessment. Choice C, while important, does not address the immediate need for monitoring the infusion rate. Choice D, maintaining the fluid at body temperature, is essential for comfort but is not as critical as ensuring the correct fluid delivery rate. By monitoring the intravenous drop rate, healthcare providers can adjust the flow as needed to prevent overhydration or underhydration, helping to manage the infant's fluid balance effectively.

4. 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.

5. A child is brought to the clinic after tripping over a rock. The child states, 'I twisted my ankle,' and is given a diagnosis of a sprain. What intervention is most important for the nurse to include in the discharge instructions for this child?

• A. For the first 24 hours, apply ice for 20 minutes and then remove for 60 minutes.
• B. Bed rest with the leg elevated for 36 hours.
• C. May take an NSAID for pain as needed.
• D. Use a compression dressing for 72 hours.

Correct answer: A

Rationale: The correct intervention for a sprained ankle is to apply ice for 20 minutes every hour for the first 24 hours, then remove for 60 minutes to prevent tissue damage. This regimen helps reduce swelling and pain. Bed rest with the leg elevated for an extended period (36 hours) may lead to stiffness and decreased range of motion. While NSAIDs can be used for pain, they may not be necessary if pain is manageable with ice and rest. Using a compression dressing for 72 hours continuously may impede proper circulation and delay healing by restricting blood flow.

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