Nursing Elites

1. What is an important intervention in providing a neutral thermal environment for an LBW infant in an incubator?

• A. Use wool blankets.
• B. Avoid using disposable diapers.
• C. Prevent heat loss.
• D. Closely monitor both incubator and rectal temperatures.

Correct answer: C

Rationale: Preventing heat loss in a low birth weight (LBW) infant is crucial in maintaining a neutral thermal environment. The use of cotton blankets is recommended over wool blankets. Avoiding disposable diapers is not directly related to maintaining a neutral thermal environment. While monitoring temperatures is important, the key intervention is preventing heat loss to ensure the infant's survival.

2. What is a clinical manifestation of acetaminophen poisoning?

• A. Hyperpyrexia
• B. Hepatic involvement
• C. Severe burning pain in stomach
• D. Drooling and inability to clear secretions

Correct answer: B

Rationale: Acetaminophen poisoning primarily affects the liver, leading to hepatic involvement, which may present as jaundice, liver failure, or elevated liver enzymes. Hyperpyrexia, severe pain, and drooling are more associated with other types of poisoning.

3. Why does the nurse have a 2-year-old boy sit in a “tailor” position while palpating for the presence of the testes?

• A. It prevents the cremasteric reflex
• B. Undescended testes can be palpated
• C. The child has an inguinal hernia
• D. The child does not yet have a need for privacy

Correct answer: A

Rationale: The tailor position stretches the muscle responsible for the cremasteric reflex, preventing it from contracting and pulling the testes into the pelvic cavity. This position helps accurately palpate the testes. Choice B is incorrect because the position does not facilitate the palpation of undescended testes specifically. Choice C is incorrect as it does not relate to the rationale behind the tailor position. Choice D is incorrect as the reason for using the tailor position is not related to the child's need for privacy.

4. A thorough systemic physical assessment is necessary in the extremely low-birth-weight (ELBW) infant to detect what?

• A. Weight gain reflective of fluid retention
• B. Difficulties in maternal-child attachment
• C. Subtle changes that may be indicative of an underlying problem
• D. Changes in Apgar score over the first 24 hours of life

Correct answer: C

Rationale: In extremely low-birth-weight (ELBW) infants, a thorough systemic physical assessment is crucial to detect subtle changes that may indicate an underlying problem. These infants are highly vulnerable and may show signs of stress through changes in feeding behavior, activity, color, oxygen saturation, or vital signs. Monitoring weight in ELBW infants primarily reflects genitourinary function rather than fluid retention. Difficulties in maternal-child attachment are important but are usually assessed during parental visits and are not the primary focus of a systemic physical assessment. Changes in the Apgar score are used immediately after birth to assess the transition to extrauterine life and are not as relevant in the following 24 hours to detect ongoing subtle issues.

5. When transitioning from intravenous to oral morphine, what would the nurse anticipate regarding the oral dose in comparison to the intravenous dose to achieve equianalgesia?

• A. Same as the intravenous dose
• B. Greater than the intravenous dose
• C. One half of the intravenous dose
• D. One fourth of the intravenous dose

Correct answer: B

Rationale: When switching from intravenous to oral morphine, a higher oral dose is required to achieve equianalgesia due to significant metabolism from the first-pass effect. Choosing the same oral dose as the intravenous dose would provide less pain relief. Opting for a dose greater than the intravenous dose is necessary to achieve the same analgesic effect. Therefore, options A, C, and D are incorrect.

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