Nursing Elites

1. During a primary survey of a child with partial thickness burns over the upper body areas, what action should the nurse take first?

• A. Inspect the child's skin color.
• B. Assess for a patent airway.
• C. Observe for symmetric breathing.
• D. Palpate the child's pulse.

Correct answer: B

Rationale: When managing a child with partial thickness burns over the upper body areas, the priority action during the primary survey is to assess for a patent airway. This step is crucial as burns in this region can lead to airway compromise, potentially causing rapid deterioration in the child's condition. Checking for a patent airway ensures that the child can breathe adequately, which is essential for oxygenation and ventilation. Inspecting the child's skin color (Choice A) is an important assessment but should follow ensuring a patent airway. Observing for symmetric breathing (Choice C) is relevant, but the immediate focus should be on securing the airway. Palpating the child's pulse (Choice D) is also a vital assessment, but in this scenario, the priority is to assess and maintain a clear airway to support respiratory function and oxygen delivery.

2. At 7 AM, a nurse receives the information that an adolescent with diabetes has a 6:30 AM fasting blood glucose level of 180 mg/dL. What is the priority nursing action at this time?

• A. Encourage the adolescent to start exercising.
• B. Ask the adolescent to obtain an immediate glucometer reading.
• C. Inform the adolescent that a complex carbohydrate such as cheese should be eaten.
• D. Tell the adolescent that the prescribed dose of rapid acting insulin should be administered.

Correct answer: D

Rationale: Rapid acting insulin will help lower the elevated blood glucose level quickly.

3. During an assessment, a nurse is examining the skin of a child with cellulitis. What would the nurse expect to find?

• A. Red, raised hair follicles
• B. Warmth at skin disruption site
• C. Papules progressing to vesicles
• D. Honey-colored exudate

Correct answer: B

Rationale: The correct answer is B: 'Warmth at skin disruption site.' Cellulitis is characterized by localized warmth at the site of skin disruption, which indicates an infection. Choice A, 'Red, raised hair follicles,' is more typical of folliculitis. Choice C, 'Papules progressing to vesicles,' is suggestive of conditions like herpes simplex virus infections. Choice D, 'Honey-colored exudate,' is associated with impetigo, not cellulitis. When assessing cellulitis, nurses should primarily look for warmth, erythema, edema, and tenderness at the affected site.

4. The nurse is admitting a newborn with hypospadias to the nursery. The nurse expects which finding in this newborn?

• A. Absence of a urethral opening is noted
• B. Penis appears shorter than usual for age
• C. The urethral opening is along the dorsal surface of the penis
• D. The urethral opening is along the ventral surface of the penis

Correct answer: D

Rationale: In hypospadias, the urethral opening is located along the ventral surface of the penis. This congenital condition results in the urethral meatus opening on the underside of the penis, rather than at the tip. Choice A is incorrect as there is typically a urethral opening present, though in an abnormal location. Choice B is not a characteristic feature of hypospadias. Choice C is incorrect as the urethral opening in hypospadias is not along the dorsal surface but rather along the ventral surface of the penis.

5. A child has undergone surgery using steel bar placement to correct pectus excavatum. What position would the nurse instruct the parents to avoid?

• A. Semi-Fowler
• B. Supine
• C. High Fowler
• D. Side-lying

Correct answer: D

Rationale: The correct answer is D: Side-lying. After surgery using steel bar placement to correct pectus excavatum, the nurse should instruct the parents to avoid placing the child in a side-lying position. This position should be avoided to prevent displacement of the steel bar. Choices A, B, and C are incorrect. Semi-Fowler, Supine, and High Fowler positions are generally safe and commonly used in postoperative care, but in this specific case, side-lying should be avoided to ensure the effectiveness of the surgical correction.

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