Nursing Elites

1. A toddler’s mother calls the nurse because she thinks her son has swallowed a button type of battery. He has no signs of respiratory distress. The nurse’s response should be based on which premise?

• A. An emergency laparotomy is very likely.
• B. The location needs to be confirmed by radiographic examination.
• C. Surgery will be necessary if the battery has not passed in the stool in 48 hours.
• D. Careful observation is essential because an ingested battery cannot be accurately detected.

Correct answer: B

Rationale: Radiographic examination is essential to confirm the location of the battery, as it can cause significant damage, particularly if lodged in the esophagus. Immediate surgery may be required depending on its location and the potential for causing harm.

2. What statement is most descriptive of Meckel diverticulum?

• A. It is present from birth.
• B. Intestinal bleeding may be mild or profuse.
• C. It occurs with equal frequency in both genders.
• D. Surgical interventions are always necessary to treat the problem.

Correct answer: B

Rationale: The correct answer is B. Meckel diverticulum often presents with intestinal bleeding, which can vary in severity. It is a congenital condition, meaning it is present from birth, not acquired during childhood (choice A). Meckel diverticulum is slightly more common in males than in females, so it does not occur more frequently in females (choice C). While some cases of Meckel diverticulum may require surgical intervention, medical interventions can also be sufficient to treat the problem, so it is not always necessary to resort to surgery (choice D).

3. During which phase of the nursing process does the nurse use essential information about the child’s physical, social, and emotional health to decide which interventions to use?

• A. Implementation
• B. Planning
• C. Diagnosis
• D. Assessment

Correct answer: B

Rationale: The correct answer is B: Planning. During the planning phase of the nursing process, the nurse utilizes essential information gathered during the assessment about the child’s physical, social, and emotional health to determine the most appropriate interventions to address the identified needs. This phase focuses on developing a comprehensive care plan tailored to the individual child. A) Implementation is incorrect because this phase involves carrying out the interventions outlined in the care plan. C) Diagnosis is incorrect as it refers to identifying health issues based on the assessment data. D) Assessment is incorrect as it involves collecting and analyzing data about the child's health status, rather than deciding on interventions.

4. What type of shock is characterized by a hypersensitivity reaction causing massive vasodilation and capillary leaks, which may occur with drug or latex allergy?

• A. Neurogenic shock
• B. Cardiogenic shock
• C. Hypovolemic shock
• D. Anaphylactic shock

Correct answer: D

Rationale: Anaphylactic shock is a severe allergic reaction that causes massive vasodilation and increased capillary permeability, leading to rapid fluid shifts and circulatory collapse if not treated promptly. Neurogenic, cardiogenic, and hypovolemic shocks have different etiologies.

5. The nurse is caring for a child after a cleft palate repair who is on a clear liquid diet. Which feeding device should the nurse use to deliver the clear liquid diet?

• A. Straw
• B. Spoon
• C. Sippy cup
• D. Open cup

Correct answer: D

Rationale: An open cup is recommended for feeding after cleft palate repair to prevent injury to the surgical site and avoid creating negative pressure, which could disrupt the repair.

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