Nursing Elites

1. A nurse is planning an initial home care visit to a mother who gave birth to a high-risk infant. For what time of day should the nurse schedule the visit for it to be most productive?

• A. When the husband is out of the home.
• B. At a time when the mother is feeding the infant.
• C. At a time that is convenient for the family.
• D. When the nurse can spend time with the family.

Correct answer: C

Rationale: Scheduling the visit at a time that is convenient for the family is the most appropriate choice. This ensures that the family is receptive and available, making the visit more productive. Choice A is incorrect because the presence of the husband may be important for support and decision-making. Choice B focuses solely on the mother and the infant's feeding time, which may not align with the family's overall availability. Choice D is incorrect as it emphasizes the nurse's convenience rather than the family's, which may not lead to an effective visit.

2. When developing the plan of care for a child with burns requiring fluid replacement therapy, what information would the nurse expect to include?

• A. Administration of colloid initially followed by a crystalloid
• B. Determination of fluid replacement based on the type of burn
• C. Administration of most of the volume during the first 8 hours
• D. Monitoring of hourly urine output to achieve less than 1 mL/kg/hr

Correct answer: C

Rationale: The correct answer is C. In fluid replacement therapy for burns, the majority of the volume should be administered within the first 8 hours to prevent shock and maintain perfusion. Choice A is incorrect because crystalloids are typically administered first in fluid resuscitation for burns. Choice B is incorrect as fluid replacement in burn patients is primarily determined by the extent of the burn injury rather than the type of burn. Choice D is incorrect as the goal for hourly urine output in burn patients is generally higher, aiming for 1-2 mL/kg/hr in children to ensure adequate renal perfusion and prevent dehydration.

3. What is a key assessment the nurse should perform for a 5-year-old child diagnosed with acute glomerulonephritis?

• A. Monitor blood glucose levels
• B. Monitor respiratory rate
• C. Monitor urine output
• D. Monitor for signs of infection

Correct answer: C

Rationale: Monitoring urine output is crucial in assessing kidney function in a child with acute glomerulonephritis. In this condition, there is inflammation in the glomeruli of the kidneys, affecting their ability to filter waste and excess fluids from the blood. Monitoring urine output helps evaluate the kidneys' ability to excrete waste and maintain fluid balance. Options A, B, and D are less relevant in the context of acute glomerulonephritis. Monitoring blood glucose levels is more pertinent in conditions like diabetes, monitoring respiratory rate is important for respiratory conditions, and monitoring for signs of infection is crucial in cases of suspected infections but is not the primary assessment focus in acute glomerulonephritis.

4. What is the most common cause of seizures in children?

• A. An abrupt rise in body temperature
• B. An inflammatory process in the brain
• C. A temperature greater than 102°F
• D. A life-threatening infection

Correct answer: C

Rationale: Seizures in children most often result from a temperature greater than 102°F, known as febrile seizures. Febrile seizures are commonly triggered by a rapid increase in body temperature due to infections or other causes. Choice A is incorrect as febrile seizures are not necessarily caused by the abrupt rise in body temperature alone. Choice B is incorrect as inflammatory processes in the brain may lead to other types of seizures but are not the most common cause in children. Choice D is incorrect as not all seizures in children are due to life-threatening infections.

5. You are caring for a 6-year-old child with a possible fractured left arm and have reason to believe that the child was abused. How should you manage this situation?

• A. inform the parents of your suspicions
• B. call the police so the parents can be arrested
• C. advise the parents that the child needs to be transported
• D. transport the child to the hospital regardless of the parents' wishes

Correct answer: C

Rationale: In cases where child abuse is suspected, the priority is the safety and well-being of the child. Advising the parents that the child needs to be transported allows for the child to receive necessary medical care without immediate confrontation or escalating the situation. Calling the police to have the parents arrested without concrete evidence may not be appropriate and could further endanger the child. Informing the parents of suspicions may lead to interference or denial of necessary care. Transporting the child to the hospital is crucial, but involving and engaging with the parents in a non-confrontational manner is the initial step to ensure the child's safety and well-being.

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