Nursing Elites

1. After surgery yesterday for gastroesophageal reflux, the nurse finds that the infant has somehow removed the nasogastric (NG) tube. What nursing action is most appropriate to perform at this time?

• A. Notify the healthcare provider.
• B. Insert a new NG tube for feedings.
• C. Replace the NG tube to maintain gastric decompression.
• D. Leave the NG tube out as it may have been in long enough.

Correct answer: A

Rationale: The most appropriate action for the nurse to take in this situation is to notify the healthcare provider immediately. This is important as the removal of the NG tube can disrupt postoperative care, especially in terms of maintaining gastric decompression. Inserting a new NG tube without practitioner direction can be unsafe and is not within the nurse's scope of practice. Similarly, replacing the NG tube or leaving it out should be decided by the healthcare provider to ensure the infant's safety and appropriate postoperative care.

2. An infant, age 5 months, is brought to the clinic by his parents for a well-baby checkup. What is the best advice that the nurse should include at this time about injury prevention?

• A. Keep buttons, beads, and other small objects out of his reach.
• B. Do not permit him to chew paint from window ledges because he might absorb too much lead.
• C. When he learns to roll over, you must supervise him whenever he is on a surface from which he might fall.
• D. Lock the crib sides securely because he may stand and lean against them and fall out of bed.

Correct answer: A

Rationale: Small objects are a choking hazard for infants, so it is crucial to keep them out of reach to prevent injury.

3. A child with acetaminophen (Tylenol) poisoning has been admitted to the emergency department. What antidote does the nurse anticipate being prescribed?

• A. Carnitine (Carnitor)
• B. Fomepizole (Antizol)
• C. Deferoxamine (Desferal)
• D. N-acetylcysteine (Mucomyst)

Correct answer: D

Rationale: N-acetylcysteine is the specific antidote for acetaminophen poisoning, working by replenishing glutathione and preventing liver damage. The other options are antidotes for different types of poisoning (e.g., Fomepizole for methanol or ethylene glycol poisoning).

4. Baby M is 5 months old. You notice that she now has the ability to grasp objects between her fingers and opposing thumb. This is known as:

• A. Parachute reflex
• B. Grasp reflex
• C. Pincer grasp
• D. Prehension

Correct answer: C

Rationale: The correct answer is C: Pincer grasp. The pincer grasp is the ability to hold objects between the thumb and another finger, typically developed around 9-12 months. At 5 months, it is early for a pincer grasp to fully develop, but the beginning of this skill can be seen as early as 5 months. Choices A and B are incorrect as the parachute reflex is a protective response to falling and the grasp reflex is an automatic response to touch. Choice D, prehension, is a general term for the act of grasping or holding objects, but it does not specifically refer to holding objects between the thumb and fingers like the pincer grasp does.

5. The nurse notes that a child has lost 3.6 kg (8 lb) after 4 days of hospitalization for acute glomerulonephritis. What is the most likely cause of this weight loss?

• A. Poor appetite
• B. Reduction of edema
• C. Restriction to bed rest
• D. Increased potassium intake

Correct answer: B

Rationale: The weight loss is most likely due to the reduction of edema, as glomerulonephritis often causes fluid retention that resolves with treatment, leading to significant weight loss.

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