Nursing Elites

1. What is an essential nursing action when caring for a young child with severe diarrhea?

• A. Maintain the IV.
• B. Take daily weights.
• C. Replace the lost calories.
• D. Promote perianal skin integrity.

Correct answer: D

Rationale: Promoting perianal skin integrity is crucial when caring for a young child with severe diarrhea as it helps prevent skin breakdown from the irritation caused by frequent stooling. Maintaining the IV (Choice A) may be necessary but is not directly related to managing perianal skin integrity. Taking daily weights (Choice B) is important for monitoring fluid status but not the priority when addressing perianal skin integrity. While replacing lost calories (Choice C) is essential, promoting perianal skin integrity takes precedence in preventing complications associated with skin breakdown.

2. A child with a diagnosis of bronchiolitis is admitted to the hospital. What is the most important nursing intervention?

• A. Administering bronchodilators
• B. Providing respiratory therapy
• C. Monitoring oxygen saturation
• D. Encouraging fluid intake

Correct answer: B

Rationale: The most important nursing intervention for a child with bronchiolitis is providing respiratory therapy. This intervention helps to maintain airway patency and improve breathing by assisting with mucus clearance and ventilation. Administering bronchodilators (Choice A) may be considered in some cases, but it is not the most crucial intervention for bronchiolitis. Monitoring oxygen saturation (Choice C) is important but is not as directly impactful as providing respiratory therapy. Encouraging fluid intake (Choice D) is important for hydration but does not directly address the respiratory distress associated with bronchiolitis.

3. The school nurse is presenting a class to a group of students about common overuse disorders. Which disorder would the school nurse include?

• A. Dislocated radial head
• B. Transient synovitis of the hip
• C. Osgood-Schlatter disease
• D. Scoliosis

Correct answer: C

Rationale: Osgood-Schlatter disease is a common overuse injury that specifically affects the knee. It is characterized by inflammation of the patellar ligament at the tibial tuberosity due to repetitive strain on the growth plate during activities such as running and jumping. Dislocated radial head (Choice A) is not an overuse disorder but rather an injury usually seen in young children. Transient synovitis of the hip (Choice B) is an acute hip condition and not typically classified as an overuse disorder. Scoliosis (Choice D) is a condition characterized by an abnormal lateral curvature of the spine and is not considered an overuse disorder.

4. A nurse is teaching a parent how to prevent accidents while caring for a 6-month-old infant. What ability should be emphasized regarding the infant’s motor development?

• A. Sits up
• B. Rolls over
• C. Crawls short distances
• D. Stands while holding on to furniture

Correct answer: B

Rationale: The correct answer is "B: Rolls over." At 6 months, most infants can roll over, which increases the risk of falls. Emphasizing the infant's ability to roll over is crucial to highlight the need for careful supervision and accident prevention. Choices A, C, and D are incorrect because sitting up, crawling short distances, and standing while holding on to furniture typically develop later in an infant's motor skills progression and are not as directly associated with an increased risk of accidents at this stage.

5. A child sitting on a chair in a playroom starts to have a tonic-clonic seizure with a clenched jaw. What is the nurse’s best initial action?

• A. Attempt to open the jaw.
• B. Place the child on the floor.
• C. Call out for assistance from staff.
• D. Place a pillow under the child’s head.

Correct answer: B

Rationale: The correct initial action during a tonic-clonic seizure is to place the child on the floor to prevent injury. This action helps protect the child from falling off the chair and provides a safer environment for the seizure to occur. Attempting to open the jaw can cause harm or injury. Calling out for assistance is important but should follow the immediate action of moving the child to the floor. Placing a pillow under the child’s head is not recommended as it may lead to airway obstruction or further injury during the seizure.

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